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Early Warning Alert and Response Network

1 Assistance Coordination Unit - EWARN

ANNUAL TECHNICALREPORT 2016

EWARN

ISSUE NO . 2

@ACU /Idleb/ 2016


ANNUAL TECHNICAL REPORT 2016Early Warning Alert and Response Network

AcronymsSection 1: Introduction

1.1 Review of EWARN team

1.2 Review of diseases in Surveillance list

Section 2: Surveillance Updates in 2016

2.1 Acute Flaccid Paralysis (AFP) Surveillance

2.2 Vaccine preventable diseases (VPD) Surveillance

2.3 Water borne diseases (WBD) Surveillance

2.4 Nutrition Surveillance

Section 3: Response Updates in 2016

3.1 Vaccination activities

3.2WASH and water quality

3.3 Laboratories and specimen’s shipment

3.4 Response and related Logistic activities

Section 4: Building capacity and Advocacy

Section 5: DMT in EWARN

Section 6: Coordination and participations

Section 7: involvement of other departments:

7.1 Media aspect in EWARN

7.2 Financial aspect in EWARN

Tableof Contents

AcronymsExecutive Summery 1Section 1: Introduction 8

1.1 Review of EWARN team 101.2 Review of diseases in Surveillance list 11

Section 2: Surveillance Updates in 2016 122.1 Acute Flaccid Paralysis (AFP) Surveillance 122.2 Vaccine preventable diseases (VPDs) Surveillance 152.3 Water borne diseases (WBDs) Surveillance 202.4 Nutrition Surveillance 23

Section 3: Response Updates in 2016 263.1 Vaccination activities 263.2 WASH and water quality 313.3 Laboratories and specimen’s shipment 333.4 Response and related Logistic activities 38

Section 4: Building capacity and Advocacy 42

4.1 Building capacity 424.2 Advocacy 52

Section 5: DMT in EWARN 53Section 6: Coordination and participations 64Section 7: involvement of other departments 63

7.1 Media aspect in EWARN 637.2 Financial aspect in EWARN 68

TABLE OFCONTENTS

EARLY WARNING ALERTAND RESPONSE NETWORK

Field Outbreak Investigation - Atmeh

Acute Bloody DiarrheaArea Coverage Survey Assistance Coordination UnitAcute DiarrheaAdverse Event Following Immunization Acid Fast Bacillus Acute Flaccid Paralysis Accelerated Implementation of Routine ImmunizationAcute Jaundice SyndromeAmbiguous vaccine-derived poliovirusAcute Watery diarrheaBivalent Oral Polio Vaccine Bill & Melinda Gates FoundationCentral Level OfficerCommunity Management of Acute Malnutrition District Level OfficerData Management TeamDistrict Nutrition OfficerExpanded Program on Immunizations Emergency Nutrition Assessment SoftwareField Level OfficerField Nutrition OfficerGerman Society for International CooperationHepatitis A VirusSurface Antigen of the Hepatitis B virus Hepatitis C VirusHepatitis E VirusHuman Immunodeficiency VirusHumanitarian Needs Overview Independent Doctors AssociationInteragency Diarrheal Disease KitsInformation Education Communication Information For Action SoftwareImmunoglobulin M Influenza Like IllnessInternational Medical Corps Integrated Management for child illnessInfant and Young Child Feeding LeishmaniasisMeaslesMeningitis Measles – Rubella

ABDACSACUADAEFIAFBAFPAIRIAJSaVDPVAWDbOPVBMGFCLOCMAMDLO DMTDNO EPIENAFLOFNOGIZHAVHBsAgHCVHEVHIVHNOIDAIDDKsIECIFAIgMILIIMCIMCIIYCFLeishMeasMenMR

Tableof Acronyms

Mid Upper Arm Circumference Non-Governmental OrganizationNon Polio Acute Flaccid ParalysisNon Polio Enterovirus Other Acute DiarrheaOffice for the Coordination of Humanitarian AffairsOpen Data KitPhysician Across Continents Polymerase Chain Reaction Quantum geographic information systemQatar Red Crescent Rapid Diagnostic TestsRapid Response TeamSyrian American Medical Society Severe Acute Respiratory Illness Syrian Expatriate Medical AssociationSyrian Immunization Group Sabin LikeStructured Query LanguageSuspected Typhoid FeverSyrian American Medical Society Tuberculosis Trivalent Oral Polio Vaccine Training Of TrainerUnited Nations International Children's FundUnusual Cluster of EventUnusual Cluster of DeathUnion of Medical Care and Relief OrganizationsVaccine-associated paralytic polio Vector Borne DiseasesVaccine Preventable DiseasesVaccine Derived PoliovirusWater-Sanitation- HygieneWater Borne DiseasesWorld Health Organization Wild Polio Virus Type 2

MUACNGONP-AFPNPEVOADOCHAODKPACPCRQGISQRCRDTsRRTSAMSSARISEMASIGSLSQLSTFSAMST.BtOPVTOTUNICEFUCEUCDUOSSMVAPPVBDsVPDsVDPVWASHWBDsWHOWPV2

Tableof Acronyms

EXECUTIVE SUMMARYAnnual Technical Report for Early Warning and Response Network

Early Warning Alert and Response Network Annual Technical Report 2016 / Issuse . 2

1 2Assistance Coordination Unit - EWARN EWARN / Second Edition

EXECUTIVE SUMMARYAnnual Technical Report for Early Warning and Response Network

Introduction:

EWARN is the health program of ACU which was launched in 10thJune 2013 as nonprofit national program. EWARN discovered the polio cases in Deir ez-Zor in 2013, since then the program has start-ed collecting epidemiological data on 13 syndromes of communicable diseases from around 500 sentinel sites. The program is the largest health program amongst all other operating programs in Northern Syria where it performs its functions through 290 members in 118 sub-districts, 38 districts in 11 governorates, and serves a population of 9,560,115 (51% of Syria total population). EWARN col-lects epidemiological data from health care facilities and camps, triggers alerts, verify and investigate, then advices on interventions based on analysis of data. Information is shared with all partners. The network is supported with laboratory services for priority diseases.

Recently, EWARN embarked on a new surveillance system on nutrition in coordination with UNICEF and other experienced partners.

SURVEILLANCE UPDATES – 2016a. Acute Flaccid Paralysis surveillance:

In 2016, AFP surveillance managed to improve both sensitivity and quality of the program. The target of NP-AFP rate was shifted from 2 to 3/100,000 population of children below 15 years of age. Cur-rently NP-AFP rate is > 5, so are all other indicators which meet global standards. All field staff are provided with smart phones for ease and timely notification. E-surveillance has just started and is expected to add to the completeness and timeliness of reporting. The system implements area cov-erage survey to all AFP cases to scrutinize the immunity status of the community, also it collects stool specimen to many AFP cases. The program adopts non-traditional ways to transport stool specimens and overcome some security obstacles. AFP surveillance will consider data analysis at sub-provincial level and develop a risk map to be ready for any importations of emergence of PV2. The system im-plements – under EWARN in coordination with all programs – a continuous quarterly training for all accessible DLOs.

Challenges:- Low level awareness of some clinicians about the importance of AFP surveillance which impact negatively the reporting of AFP cases.

- Increasing work load on the staff.

Plans - 2017- Expand the training on AFP surveillance to involve more practicing physicians with

advocacy activities. That would include private physicians.

- Expand sensitization and training to new categories of health care providers and pilot

community-based surveillance in particular provinces.

- Practicing E-surveillance.

- Upgrading the IFA version in view of identified technical problems in data entry and analysis.

- Enhance the active surveillance.

b. Vaccine Preventable Diseases:

Since 2012, many outbreaks of vaccine preventable diseases have started to emerge, e.g. polio, mea-sles. This upsurge of incidence of VPDs was a natural result of interruption of Expanded Program on Immunization due to military crisis in Syria. In 2016, EWARN has been instrumental in detecting these outbreaks and triggering alerts and participation in response activities including investigation, labo-ratory confirmation as well as planning & implementation of vaccination campaigns. The appearance of these outbreaks helped the improvement of VPD surveillance, and urged all partners to implement vaccination activities. Since June, 2016, measles and German measles has started to shift towards cased-based surveillance system. Other VPDs like pertussis, mumps and tetanus will continue with surveillance based on aggregate data.

VPD data are shared with all partners especially SIG to help develop suitable vaccination schedule of mass vaccination until routine immunization program is re-vitalized. In 2016 a downward trend of measles was observed which could be due to implementation of MR & AIRI campaigns.

In addition, EWARN has been active in detecting adverse events following immunization (AEFI)

Challenges:- Low level of awareness on reporting of VPDs among health care workers for reporting.

- Lack of training of some DLOs due to inaccessibility.

- Security concerns which affect the completeness and quality of reported data.

- Lack of Lab capacities in some areas.

- Improper utilization of surveillance data to guide and support SIG performance in responding

to VPDs outbreaks. More coordination is needed

Plans - 2017- Continue and further improve measles case – based surveillance.

- Improve measles surveillance indicators to the level of international standards.

- Upgrading VPDs surveillance in general.

- Cooperating with SIG to achieve a clear strategy for VPDs outbreaks response.

- Producing and issuing VPDs surveillance Bulletin.



c. Water-borne diseases:

Since the launch of EWARN, water borne diseases were recognized as a priority due to high morbidity and high potential of epidemics, in addition it strongly reflects the quality of WASH services.

Currently, WBD surveillance has a strong integration with Laboratory, WASH and implementers in order to monitor the trends, and evaluate the implemented activities. The main priority in this part of disease surveillance is to focus on: the rapid detection of suspected cholera cases.

EWARN works closely with the Cholera Technical Group mainly in the areas of needs assessment, resource mapping for preparedness plan, building capacity, generating Cholera risk map weekly and provide diagnostic tools (RDTs - Carry Blair media), in addition to securing 10 IDDKs.

In 2016, more than 31 alerts of WBD and 13 suspected cases of cholera were detected and investi-gated.

Challenges:- Lack of well integrated cholera preparedness plan in besieged areas is really.

Plans - 2017- Generate the cholera risk scale for all covered areas.

- Replace the almost expired tools with a new valid set.

- Conduct refresher training on cholera preparedness for the health workers.

d. Nutrition surveillance:

A new surveillance system for Nutrition is being established now, with major objective of monitoring the nutritional status among children under 5 years regularly as part of an early warning system, Thus provide early indication of likely trends in nutrition conditions, and providing information that can be used for advocacy. An assessment of the current situation was conducted to identify the gaps and assess the already existing services.

The program will be established on facility level (in the 1st phase). 100 facilities in 8 governorates were selected according to certain criteria such as accessibility and trends of diarrheal diseases. MUAC and bilateral pitting edema are the indicators selected to identify malnutrition.

Challenges:Sustainability, the competition between implementers and linking information to action are the ma-jor challenges.

Plans - 2017- Moving the surveillance system to community-based surveillance.

- Adding the anthropometry indicators.

- Building the capacity of the team to join: CMAM – IYCF – IMCI

- Promote the quality of malnutrition surveillance data to provide sound evidences for

further actions.

RESPONSE UPDATES – 2016a. Vaccination activities:

Vaccination team of EWARN has contributed significantly in all vaccination activities of 2016. The team has participated in AIRI 1, 2, 3 and Polio as well as MR campaigns. The team has immi-nent role in developing the micro-plans; training and supervising campaigns. The presence of the team in many areas inside Syria has enabled the team to mobilize the vaccine between different regions and monitor campaign performance. Vaccination team has played a major role in OPV switch and containment of tOPV where it has been destroyed.

Challenges:1. Security issues: the vaccination centers have been targeted many times by the air strikes, which resulted in loss of many vaccinators and supervisors.

2. Destruction of health facilities with decreased ability to conduct EPI.

Plans - 20171. Intensify staff training.

2. Increase the team to meet the increasing workload.

3. Coordinate with Turkish Government to grant permanent permission to access through the northern Turkish - Syrian boarders, in order to facilitate the logistics and supervision.

b. WASH & water quality:

In April 2015, WASH team has been established in EWARN . The team had 10 technical members covering 6 governorates. In October, 2016 the program has expanded to cover 10 Governorates and team has increased to 22 staff members.

WASH activities focus on monitoring quality and safety of drinking water alongside the whole network. It plays an important role in alerting all partners on the safety of water in a proactive manner, it also responds to situations where water borne diseases are emerging. WASH work in partnership with all partners who share same activities like UNICEF, it is also a recognized mem-ber of WASH-cluster. Recently the WASH team has provided field staff with mobile laboratories and other chemicals and reagents to monitor biological and chemical characteristics of drinking water. WASH team participate in all trainings for district and field staff especially on emergency situations as in case of alerting for cholera.

Challenges:- The difficulty of accessing some areas due to change of control forces.

Future plan:1. Adding new field officers to expand the coverage.

2. Secure procurement of laboratory equipment Secure procurement of chemicals and steril-ization materials and reagents (such

3. Workshops and training of staff.

4. Awareness campaigns in high risk areas and participating in response missions.

5. Continue preparing the studies of water and sanitation for rehabilitation projects



c. Laboratories & specimen's shipment:

EWARN has improved the laboratory system and increased its diagnostic capacity which adds to the quality of laboratory surveillance. The first laboratory was established in rural western Aleppo in 2015 with assistance from Italian government. In 2016, equipment for culturing was provided (Bacterial safety cabinet, CO2 incubator and culture media…) where culture of suspect cases of salmonella and cholera was possible. Equipments were provided by WHO for the two laboratories in Azaz and Edlib.

Challenges:1. Lack of funding and logistical support

2. Poor infrastructure, electricity problems and lack of basic equipment and consumables.

3. Scarcity of the qualified trainers and training activities in the lab field and qualified technicians for maintenance

4. Unavailability of Universal control

5. Border problems that leads to delay or inability to ship the materials and the lack of fund to up-grade the available equipment when needed.

Future Plan:1. Activating the labs in Idleb city and Azaz.

2. Equipping the labs in besieged areas with the minimal needs for outbreak confirmation in order to take the needed steps for response.

3. Activating Real Time- PCR and the blood culture.

4. Looking for support in continuous training in immunology and macro-biology field to include this field in our scope of tests.

5. Increasing the capacity of EWARN labs inside Syria and the lab staff.

6. Refresh the training on safety procedures.

7. Continuous maintenance of the lab equipment and having back-up equipment to insure the continuity of the work without any cut offs.

BUILDING CAPACITY & ADVOCACY:

Training is an essential component of EWARN. Training boosts the quality of surveillance and re-sponse activities. Training activities encompasses not only health workers of EWARN, but also work-ers of other NGOs operating inside Syria. Training in 2016 aimed at improving quality of process and accuracy of surveillance and response activities.

3 training sessions were conducted for NGOs health workers each of them included more than 220 participants .

Challenges:1. Difficulty in crossing borders to attend the critical quarterly training of DLOs.

2. Difficulty of conduct same training inside Syria for FLOs.

Future Plan:1. Continue training of DLOs/FLOs

2. Conduct high level training by credible organization e.g. CDC

DATA MANAGEMENT

DMT is considered the web that links the departments with each other, through analysis and proper visualization until reporting and sharing information. The technical support helps in the capacity building for the rest of the team on required computer skills and finding proper solutions for the encountered challenges.

DMT takes into account the importance of knowledge exchange and being open to exchange expe-riences of others.

So many tools were developed to study the syndromes, and to get summaries efficiently.

Focus on strengthening the electronic filing system at the CLO level.

Great efforts are being made, to generate interactive maps and to utilize new elegant tools such as Microsoft Power BI for data analysis and visualization and Open ODK for mobile data collection. The team will embark on implementation of E-surveillance next year.

d. Response and Logistic:

In two years time, the program has achieved significant progress in epidemic diseases surveillance and outbreaks investigation and response. The availability of large amount of epidemiological data showed an urgent need to set up rapid response system for any potential outbreak.

To develop this response capacity, a plan has been developed taking into consideration the logistic requirements Six EWARN team members have been trained and assigned to high risk areas , and more than 48 response missions have been performed, with the proper field procedures. Increase the number of the warehouses from 2 (in 2015) to 6 warehouses .

Challenges:1. The deteriorating security situation

2. Some areas are hard to reach because of the bomb attacks or Fighting

3. Inaccessibility to some areas.

4. In some areas laboratories are not found.

Future Plan:1. Expanding the response team, especially in eastern areas (Deir-ez-Zor- Ar-Raqqa – Al Hasakeh).

2. Allocate a proper space in the health institutes to isolate and manage the infected cases.

3. Strengthen the collaboration and coordination with the organizations with experience in epidem-ics response.



a. Financial aspect in EWARN:

Financial stability played a key role in the success and in expanding the EWARN activities. Most of the financial aspects have been stable, the key challenge remains in Timing of cash flow as it is critical for program validity and credibility. Maintaining that was a little bit of a challenge, especially at the start of 2016, as grant reporting and getting approval for 2016 plan required time and procedures.

Based on that we plan to process end of year expenses earlier with defined deadlines for our staff inside Syria to make sure there is more time available for grant reporting and the process of New Year grant approval.

Also more attention will be paid to the timing of cash out flows as it is concentrated in the last quarter of each year due to materials purchasing and stocks replenishment process

Also, EWARN plans to expand the direct payment method where applicable as it gives more credibility to the program.

COORDINATION AND PARTICIPATION:

EWARN has regularly participated in 6 working groups ( in Turkey , Jordan and Syria ), which strength-en its role in identifying the humanitarian needs and evaluating the ongoing projects and plans .

EWARN became an essential player in the operations in the humanitarian society, with multi-level and highly organized coordination with: WHO , UNICEF , NGOs , INGOs , local authorities in the differ-ent areas controlled by different parties and other forces .

INVOLVEMENT OF OTHER DEPARTMENTSa. Media:

The importance of having a clear media plan was raised in order to connect to active and attractive channels with stakeholders, partners, beneficiaries and public.

That could be summarized in the following items: improving and updating the Website,Google Ad-Words sponsored advertisements, social media, interactive map, producing animation films, and de-signing more than 25 high quality IEC materials to facilitate sending the messages and create an easy communication method.

SECTION 1: INTRODUCTION Annual Technical Report for Early Warning and Response Network



SECTION 1: INTRODUCTION Annual Technical Report for Early Warning and Response Network

EWARN was launched on 10th June 2013 as nonprofit national health information surveillance system, its main mission is collecting epidemiological data from sentinel sites, analysis then sharing the results with the health institutes and stakeholders to guide proper decisions and needed actions for supporting and further improving health services in Syria.

- The network started in 61 sub- district in 7 governorates.

- In September 2014 the system expanded in Rural Damascus (east Gota) and Dar`a governorates.

- In March 2015, west part of Dar`a and Quneitra, besieged rural north of Homs and northern of Al-Hasakeh.

- In 2016 many areas witnessed a switch in the control forces, thus a new team was trained and assigned in the field (South Al-Hasakeh–Menbij), in addition, new areas were added to the network coverage: eastern Homs (AL Badiya) and western Rural Damascus (western Gota).

Figure 1: Coverage map for EWARN _ end of 2016

EWARN now covers118 sub districts in 38 districts for 11 governorates, covering a 51% of the population (9,560,115).

GOVERNORATE Syria Population_HNO EWARN Population Population% Area %

Aleppo 2,496,394 1,855,737 74% 63%

Al-Hasakeh 1,054,164 900,859 85% 59%

Ar-Raqqa 1,427,707 1,427,707 100% 100%

As-Sweida 320,690 - 0% 0%

Damascus 1,759,800 105,000 6% 0%

Dar'a 939,872 828,602 88% 71%

Deir-ez-Zor 1,839,452 1,686,772 92% 84%

Hama 1,337,108 94,428 7% 31%

Homs 1,496,803 243,243 16% 33%

Idleb 1,818,712 1,818,712 100% 100%

Lattakia 909,746 - 0% 0%

Quneitra 50,550 48,130 95% 76%

Rural Damascus 2,636,585 540,925 21% 5%

Tartous 753,256 - 0% 0%

All of Syria 18,840,839 9,560,115 51% 50%

Syria Population_HNO

18,840,839 All of Syria

EWARN Population

9,560,115All of Syria

Area %

50%All of Syria

Population%

51%All of Syria

*The population percentage is calculated based on the census-2016 provided by HNO – OCHA and SIG

The area percentage is calculated based on the national areas of Syria sub-districts

Table 1: The population percentage and Area percentage that covered by EWARN -2016



Table 2 : EWARN team review per year

Time period CLOs Manager Surveillance Response Data DLOsResponse

team in field

WASH team in

field

Lab team in field

FLOs Total

2013 5 1 1 3 - 16 - - - - 21

Mid of 2014 6 1 1 3 1 22 - - - 28

Start of 2015 8 1 2 3 2 24 - - - 181 213

October 2015 12 1 3 4 + 1 WASH 3 29 4 10 2 214 271

December 2016 15 1 3 5 + 2 WASH 4 30 6 20 7 212 290

EWARN and WHO reviewed case definition for the diseases in May 2016, thus many of them were updated in definition and/or alert threshold.

Case Definition Alert Threshold

Other Acute diarrhea (OAD) Any person with acute diarrhea (three or more loose stools in the past 24 hours); not due to bloody diarrhea or suspected cholera.

Double the average of the last 3 weeks in a given location

Acute watery diarrhea (AWD):Any person aged 5 years or more with severe dehydration OR death from acute watery diarrhea in the past 24 hours), with or without vomiting.

one case

Acute onset of jaundice (yellowish sclera or skin or dark urine), AND Severe illness (Fatigue, nausea, vomiting and abdominal pain) AND The absence of any known precipitating factors.

≥ 5 cases in 1 location in 1 week

Influenza Like Illness (ILI):Acute respiratory illness with: measured fever (≥ 38°C) and Cough with Onset within the last 7 days

Double the average of the last 3 weeks in health facility

Severe Acute Respiratory Illness (SARI):Acute respiratory illness with: History of measured fever (≥ 38°C) and Cough within onset within the last 7 days; Case requires hospitalization (whether possible or not )

≥ 5 cases in 1 health facility or hospital in 1 week OR 1 death due to influenza like illness

Suspected Meningitis (Men):Any person with sudden onset of fever ≥ 38°C, AND ONE of the following signs:-Neck stiffness. -Bulging fontanel (in a child < 1 year).-Altered consciousness.-Petechial or purpuric rash OR other meningeal signs

1 case in a crowded camp setting OR Population ≤ 30.000: 2 cases per week in the same community OR Population ≥30,000: 5 cases per week in the same community

Unusual cluster of health events (UCE):Any emerging disease or event of an unknown or unidentifiable cause resulted in suffering of many people from similar symptoms in the same location in given short period of time.

3 or more cases in same week in the same community or health facility

Unusual cluster of death (UCD):Persons who die suddenly of unknown, non-injury cause with same signs or symptoms and do NOT have any of the diseases or syndromes listed above.

3 or more deaths in same week in the same community or health facility

Suspected Typhoid Fever (STF):Any person with acute illness and fever of at least 38° C for 3 or more days with GIT symptoms; diarrhea or constipation or abdominal tenderness pro-gressing to prostration and relative bradycardia OR symptomatic case who is in contact with confirmed case

≥ 5 cases in 1 location in 1 week

Cutaneous Leishmaniasis (Leish):Any person having skin lesions on the face, neck, arms, and legs (exposed body parts), which began as nodules and turned into skin ulcers, eventually healing but leaving a depressed scar.

≥ 50 of new case in one area or health facility.

FUO: were removed from the surveillance list, to be under STF or UCE.

TimeThe highlighted cells refer to added diseases to the surveillance list

*The highlighted codes refer to modification in case definition or / and alert threshold

2013 ABD AWD AJS AFP Mea Men SARI FUO UCE UXD - - - -

2014 ABD AWD AJS AFP Mea Men SARI FUO UCE UXD STF Leish - -

2015 ABD AWD AJS AFP Mea Men SARI FUO UCE UXD STF Leish AD ILI

2016 ABD AWD AJS AFP Mea Men SARI - UCE UCD STF Leish OAD ILI

Table 4 : Diseases / Syndromes in surveillance list review per year

1.1 Review of EWARN team 1.2 Review of diseases in Surveillance list:

SECTION 2: SURVEILLANCE UPDATES IN 2016Annual Technical Report for Early Warning and Response Network



SECTION 2: SURVEILLANCE UPDATES IN 2016:Annual Technical Report for Early Warning and Response Network

The onset of the polio outbreak in 2013 signified the importance of EWARN and AFP surveillance; the EWARN team started collecting data and samples despite the very limited experience and security challenges within Syria. The technical support provided by WHO at that time helped the improvement of AFP surveillance activ-ities and indicators.The main objective of the AFP surveillance program is improve the sensitivity and quality of the program so as not to miss poliovirus circulation

2016 updates:The areas of coverage and improved surveillance for AFP increased as EWARN coverage expanded in 2015, which lead to more reporting of the AFP cases. The indicators in 2015 showed remarkable improvement when compared to 2014. Based on that the aim for 2016 was to even achieve more improvement in the performance indicators despite all the challenges in the field; The NP-AFP rate increased from 2/100.000<15 years old to 3/100.000<15 years old; The Area Coverage Survey (ACS) is practiced and included in case investigation forms; established fixed criteria for the Hot cases (Age< 60 months, fever, asymmetry and rapid progress less than 4 days); As of May 2016 the team started collecting contacts specimens for all AFP cases, and in order to achieve timely notification, all field staff were provided with smart phones.Detecting the aVDPV case at the end of 2015 stressed the importance of early detection and investigation of all AFP cases improves preparedness to respond quickly as soon as a PV2 is detected starting from September 2016.A weekly meeting is held in coordination with the WHO focal point, to review and discuss the AFP surveillance indicators with discussions on possible actions and solutions for surveillance and immunization.

Indicators review per year

Indicator 2014 2015 2016

Reported Cases 106 267 344

NPAFP Rate 2.5 5.1 5.4

Adequacy Rate 62.3 79 80.5

NPEV 33 15 17.3

SL 3.8 1.5 2.9

Table 5 : Indicators review per year

Figure 2: 2015 - Distribution of polio and non-polio AFP cases by classification and week of onset

Figure 3: 2016 - Distribution of polio and non-polio AFP cases by classification and week of onset

Confirmed case of December 2015 is aVDPV

2.1 Acute Flaccid Paralysis (AFP) Surveillance



ADEQUACY 2015 - 2016

Figure 5: Stool Adequacy rate 2015 - 2016

NPAFP RATE 2015 - 2016

Figure 4: Non-Polio AFP rate (2016)

1. Reluctance of some physicians to report AFP cases.2. Excess workload.3. Difficult reporting from eastern governorates due to difficulties in Internet connection. 4. Difficulties in face-to-face training of some DLOs (southern governorates, Al-Hasakeh, Rural Damascus, Homs), as a result Skype is being used instead. 5. Delayed shipment of stool specimens from the eastern governorates and southern governorates. Some stool specimens from besieged areas are kept frozen and not sent to laboratory since 2015.

2017 plan:Despites the fact that the AFP surveillance t is one of the most well established components of EWARN, there is still room for a great deal of improvement to overcome the challenges in the field.

Challenges:

1. Expanding the training of the physicians from all specialties in order to keep sensitizing them about the importance of early detection and reporting. Also expanding the training scope on AFP to include the more peripheral level of the health workers and finally including the community itself to achieve the community-based surveillance.

2. Utilizing the e-surveillance for timely data collection.3. Increasing the field staff to overcome any obstacles related to access and security.4. Upgrading the current IFA version to help trouble shooting. 5. More focus on the active surveillance. 6. Special focus on studying AFP cases with zero doses and sharing data with SIG to inform decisions on frequency and scale of polio campaigns and support strengthening of routine immunization.7. In depth analysis of AFP cases with inadequate stool specimens and propose additional surveillance activities8. Developing for first time polio risk map for Syria for better preparedness and response

EWARN was established in 2013 to cover diseases with high epidemic potential. It started with AFP (suspect polio) and suspect measles.

Following the disruption of the EPI program in non-regime control areas, VPDs' outbreaks were detected due to lack of vaccines (poliomyelitis and measles in 2013 and 2014 respectively). Later on, incidence of other VPDs showed an increasing trend in different areas of north of Syria (measles, pertussis, mumps and T.B), as compared to times when EPI was functional.

The importance of VPDs surveillance was further improved and increased after re-activation of vaccination activities in mid-2016 where first multi- antigen campaign was carried out in northern governorates of Syria; measles surveillance was shifted to case-based around same time of the year. Furthermore, the Syrian Immu-nization Group (SIG) based in the north of Syria intends to re-activate the routine expanded program on immu-nization (EPI) in the foreseen future.

In addition, EWARN collaborates with SIG in all vaccination campaigns, as well as monitoring adverse events following immunization (AEFI) on a daily basis.

2.2 Vaccine preventable diseases (VPDs) surveillance



- Since mid 2016, EWARN shifted from aggregated surveillance to case- based surveillance for measles; this shift has variable levels of implementation depending on the prevailing security situation and accessibility. - Measles & rubella investigation forms were reviewed and updated, and an excluded list was introduced.- A referential measles report (bilingual) will be produced compiling all measles data of 2014 up to 2016.- Observation of a significant decline in the number of suspected and confirmed measles cases after immu-nization campaigns conducted by SIG in 2016.

VPDs surveillance activities:

(A) Measles surveillance

- Aggregate data-based surveillance was introduced for pertussis, mumps, rubella and T.B. Data of those diseases include minimum data on age, sex, date of onset and vaccination status. - Two pertussis outbreaks were investigated in Deir-ez-Zor governorate.- Case-based surveillance could be established for other priority communicable diseases in the future if deemed necessary.

(B) Other VPDs surveillance

- Follow-up, reporting and monitoring of AEFI during vaccination campaigns through EWARN staff in the field.- Follow-up and investigate all the medium and high-risk cases.- Publish two reports about AEFI: measles and rubella vaccination campaigns and 1st routine vaccination campaigns.

(C) AEFI surveillance:

The main Results (Work Indicators) in 2016:

1- 283 suspected cases completely investigated.2- More than 226 suspected cases were sampled and tested in the laboratories, with positive results for 89 measles cases and 8 rubella cases.3- Significant decrease in suspected and confirmed measles cases after three routine vaccination campaigns (including MR vaccine) in northern Syria compared to 2015.

Measles:

Figure 6: The Reported Suspected Measles cases compared to the previous 2 years

64692209

1884

2014 - Total cases

2015 - Total cases

2016 - Total cases

Figure 7: Distribution of suspected measles cases by Governorate until 2015- 2016 (Epi wk 37 )



GOVERNORATE Number of cases 2016

Incidence rate for 100.000 of population

2016

Number of cases 2015

Incidence rate for 100.000 of population

2015

Aleppo 500 26.7 641 34.2

Al-Hasakeh 59 6.1 389 40.3

Ar-Raqqa 908 58.6 665 42.9

Dar'a 27 3.3 20 2.4

Deir-ez-Zor 414 23.0 280 15.6

Hama 9 6.4 20 14.2

Homs 45 18.2 0 0.0

Idleb 188 10.1 175 9.4

Quneitra 4 8.3 2 4.2

Damascus 0 0 6 5.7

Rural Damascus 12 2.2 11 2

Total 2116 21.8 2209 22.2

1- More than 2500 suspected case of pertussis were reported; the most affected governorates were Deir- ez-Zor, Ar-Raqqa Ar-raqqa and Idleb.2- More than 2300 suspected cases of mumps were reported (especially in Aleppo and Idleb); the majority of cases were properly investigated and laboratory confirmed.3- More than 631 new TB cases were reported in 20164- 62 cases of Hepatitis B were confirmed by the EWARN Laboratories.5- In general, the numbers of VPDs started to decrease following the implementation of the AIRI campaign in the northern governorates.

Figure 8: VPDs suspected cases up to Epi week 37 – 2016

Other VPDs:

Following up the AEFI as follow:AEFI surveillance:

Figure 9: Governorates with Highest VPDs reports during 2016 as of Epi week 37

Vaccination Campaign Date No. of zero reports No. of AEFI recorded

1st Measles and rubella March - April 868 More than 80

1st round of AIRI (Penta, MR, OPV) May - June 1052 More than 416

2nd round of AIRI (Penta, IPV, OPV) and with MR in : Jarablus – Tell Abiad – Ain ALArab (Kobani)

July - August 501 More than196

3rd round of AIRI (Penta, MR, OPV) November - December 609 More than 340

Table 7: The details of AEFI follow-up during the vaccination campaigns

1- Low level of awareness among health care workers of need for reporting of diseases under surveillance.2- Inaccessible field staff who did not receive our essential training on case definition and surveillance processes. 3- Security concerns in some areas which leads field staff to only collect the basic data without collecting necessary specimens.4- Lack of lLab capacities in some areas (Besieged areas - ISIL controlled areas ).5- Improper utilization of surveillance data to guide and support SIG performance in responding to VPDs outbreaks. More coordination is needed.

2017 plan:

Challenges:

1- Continue and further improve measles case – based surveillance2- Improve measles surveillance indicators to the level of international standards.3- Upgrading VPDs surveillance in general.4- Cooperating with SIG to achieve a clear strategy for VPDs outbreaks response.5- Producing and issuing VPDs surveillance Bulletin.

Table 6 : Incidence rate of measles cases by governorate (2015 - 2016)



1- Verified and investigated more than 31 WBDs alerts in 6 governorates, with the adequate sampling (stool)

or blood culture, serum) and testing of water sources. The details of the response actions are mentioned in the logistic and response activities.

2- Secured and provided the needed logistic for suspected cholera cases investigation (RDTs) and sampling media (Carry Blair ) to DLOs in all the areas except Homs and Rural Damascus (besieged).3- Received and shipped 10 complete IDDKs, to preposition them in the main warehouses in Aleppo city ( A’zaz – Afrin and Bab Al Hawa) to prepositioning so they are available if the need arises.

4- Actively participated in Cholera Technical Group meetings, to presenting O updates and trends cooperating with the partners to finalize the cholera preparedness plan.5- Generated the Cholera risk map in northern Syria on weekly basis, and share it with both Health and WASH clusters, in addition to cholera technical group. 6- Detected 13 suspected cases of cholera up to EPI WEEK 42, RDTs were used for 7 cases and stool culture for 3, all the results were negative.

- Since the launch of EWARN in 2013, three water borne diseases were included in the list (AJS – ABD and AWD) as they are diseases with high morbidity diseases and have epidemic potential. This group of diseas-es strongly reflects the quality of WASH services provided.

- In April 2015 AD was added to the surveillance list as an important indicator of the high risk areas for possible cholera outbreak. - On In September 2015, the Health Cluster (Turkey Hub) called a meeting to address the situation following the cholera outbreak in Iraq, that was attended by the WHO representative, ACU/EWARN and other NGOs. - In July 2016, the Health Cluster (Turkey Hub) called again for revitalization of the task force under the name of Cholera Technical Group. The EWARN team is involved to provid the following to the group :

Related Activities: Highlights:

1) Needs assessment: Identify gaps, needs and capacities (coordination and technical) using appropriate tools for gap/need analysis.2) Resource mapping including logistics, and supplieslogistics, supplies, and human resources.3) Risk assessment related to cholera prevention, preparedness and response.4) Provide technical support to cluster partners to build response capacity during the outbreaks.

- Currently, WBDs surveillance has a strong and high level coordination with: Lab team, WASH team and health workers in order to monitor the trends, and evaluate the implemented activities.- The main priority in this part of disease surveillance is to focus on: the rapid detection of suspected cholera cases, the early investigation of suspect cases, to get the proper sampling and to hold the sufficient education and awareness about the disease and case management.

Figure 11: Cholera Risk Maps for Epi weeks 40 and 41

Figure 10: IDDKs and Cholera sampling tools distribution

2.3 Water Borne Diseases (WBDs)



Figure 12: Negative RDT for one suspected Cholera case with negative stool culture result

Challenges:

a. WBDs are endemic in Syria. Control procedures need a strong coordination between all partners and sectors, which is very challenging and high cost implications.b. Inability to have full and strong preparedness plan for Cholera outbreak in besieged areas because of security (difficulty of provision of IDDKs and sampling tools). However, there is proper early detection of suspected cases due to good understanding of case definition of suspect cholera suspected cholera.

Figure 13: No. of reported suspected cholera cases in 2016 by district

2017 Plan:

- Generating the cholera risk scale for south of Syria, through coordination with the Health and WASH sectors in Jordan`s Hub in order to obtain the needed indicators for calculation.- Replace the equipment to expire in 2017- for both IDDKs and RDTs - with new valid set. - Conduct refresher training concerning cholera preparedness for the health workers, to get them ready for any possible outbreak.

In conflict areas with complex emergencies, there is a need for the establishment of a nutrition surveillance system. This system needs to receive accurate, regular and timely data. This is a key to make rational decisions for humanitarian interventions.

The overall objectives of this system are to:

- Measure and monitor nutritional status among children under 5 years regularly as part of an early warning system.- Provide early indication of likely trends in nutrition conditions.- Providing information that can be used for advocacy and for promoting accountability for actions or lack of actions.

Figure 14: Coverage map for the nutrition surveillance _ phase 1

2.4 Nutrition Surveillance



Figures 15, 16 : FNOs training in Atmeh

Figures 17, 18: DNO training in Aleppo city

Implementation steps:

1- Pre surveillance:- Assessment of the current situation: assess existing services by using the 4ws nutrition cluster informa-tion, to identify the gaps .The surveillance will be established at the facility level (in the 1st phase).- Types of information will be required: using 2 indicators: MUAC and bilateral pitting edema to monitor the trends of acute malnutrition cases

2- Implementation: - The areas chosen were based on the following criteria: accessibility, number of diarrheal cases, number of consultations, availability of the health workers training and previous expertise. At the moment the program will be implemented in 100 facilities for 8 governorates. - Determine the most appropriate and effective data flow for current situation- Design the data collection and reporting tools- Develop and implement training for data providers and data users with the proper guidelines. Apply standardization test after the training. - Pretest the system and, if necessary, redesign the system for data collection, data flow and data processing.

3- Evaluation:Via the indicators of supervision and data quality follow up, in order to enhance the surveillance system.The program will be supported by UOSSM for 10 months duration.

1- Sustainability: the inability to provide the necessary resources needed to maintain the system- as it is a new program just funded for 9 months (very challenging). 2- The competition: EWARN plans for nutrition surveillance where many other competing NGOs are working as well on nutrition surveys and management. The system needs to be empowered and greatly facilitated to achieve high quality performance.3- Linking information to action: involvement of decision-makers in the design and development of an analytical framework for using the information will strengthen the credibility of the program and, as a result, the probability of a response where necessary.

2017 plan:

Challenges:

- Move to community-based-surveillance to avoid the bias from facility -based surveillance. - Add another anthropometry indicator (weight and height) to the procedures of detecting malnutrition.- Building the capacity of the team to let them able to join the needed programs: CMAM – IYCF – IMCI.- Promote the quality of malnutrition related efforts (including the provision of the treatment materials) to be evidence based. Might rewrite—Promote quality evidence based surveillance data to improve nutrition programming, including the provision of supplies.

Annual Technical Report 2016 / Issuse . 2

27EWARN / Second Edition

SECTION 3 : RESPONSE UPDATES IN 2016 Annual Technical Report for Early Warning and Response Network

EWARN Lab - Bacterial Culture



SECTION 3 : RESPONSE UPDATES IN 2016 Annual Technical Report for Early Warning and Response Network

Following the establishment of SIG technical group co-chaired by WHO and UNICEF, EWARN has sup-ported this group with staff in both central and field levels, with an effective role in both coordinating and implementation the various activities of polio and routine immunization campaigns. In addition, the vaccination group of EWARN has been very instrumental in implementing the global switch policy from tOPV to bOPV.

A. Activities implemented: Participation with SIG in supervision on the following vaccination campaigns: - 12th round Polio- Measles and Rubella campaigns. - 3 Routine Immunization (AIRI1,2 and 3) rounds- Expanded vaccination program has been scheduled.

# Round Gov/Dist Start End

Polio_R12 Northern Homs 31-Jan-16 5-Feb-16

MR_1 Ar-Raqqa 28-Mar-16 6-Apr-16

MR_1 Deir-ez-Zor 28-Mar-16 6-Apr-16

MR_1 Eastern Aleppo 31-Mar-16 9-Apr-16

AIRI_1 Ar-Raqqa 13-Jun-16 22-Jun-16

AIRI_1 Deir-ez-Zor 13-Jun-16 22-Jun-16

AIRI_1 Eastern Aleppo 3-Jul-16 11-Jul-16

AIRI_1 Northern Homs 3-Jul-16 11-Jul-16

AIRI_1 Al Badiya 16-Jul-16 22-Jul-16

AIRI_2 Northern Homs 19-Sep-16 28-Sep-16

AIRI_2 Jarablus 5-Oct-16 14-Oct-16

AIRI_2 Tell Abiad 19-Oct-16 27-Oct-16

AIRI_2 Ain Al Arab (Kobani) 19-Oct-16 27-Oct-16

AIRI_3 Northern Homs 12-Nov-16 19-Nov-16

AIRI_3 Jarablus 26-Nov-16 3-Dec-16

Table 8 : Round's Dates_2016

Governorate /Area

Polio R12 MR AIRI 1/OPV

AIRI 1 /Penta

AIRI 1 /MR

AIRI 2 /OPV

AIRI 2 /Penta

AIRI 2 /IPV

AIRI 2 /MR

AIRI 3 /OPV

AIRI 3 /Penta

AIRI 3 /MR

Vit A / Blue Cap

Vit A / Red Cap

Aleppo 264,922

Idleb 324,448

Lattakia 10,314

Hama 20,230

Ain Al Arab

(Kobani)19,240 18,663 17,316

Al-Hasakeh 47,350

Ar-Raqqa 213,269 180,576 201,000 194,970 180,900

Deir-ez-Zor 309,420 243,294 284,800 276,256 256,320

E. Aleppo 242,119 217,589 113,000 109,610 101,700

E. Hama 8,905

E. Homs 12,897

N. Homs 41,500 36,550 35,350 32,750 36,450 35,358 13,488 36,450 35,357 32,805 3,645 29,160

Al Badiya 25,200 24,450 22,680

Jarablus 20,100 19,497 18,090 16,455 15,963 14,810

Tell Abiad 28,163 27,320 25,348

Total 1,495,374 641,459 660,550 640,636 594,350 103,953 100,838 13,488 60,754 52,905 51,320 47,615 3,645 29,160

Governorate / Area

R12 MR AIRI 1/ OPV

AIRI 1/ Penta

AIRI 1 /MR

AIRI 2 /OPV

AIRI 2 /Penta

AIRI 2 /IPV

AIRI 2 /MR

AIRI 3 /OPV

AIRI 3 /Penta

AIRI 3 /MR

Vit A / Blue Cap

Vit A / Red Cap

Aleppo 258,757

Idleb 342,715

Lattakia 3,399

Hama 20,508

Ain Al Arab

(Kobani)16,094 14,511 13,871

Al-Hasakeh 50,634

Ar-Raqqa 217,649 164,733 195,075 160,625 130,960

Deir-ez-Zor 315,431 222,003 270,235 247,460 210,664

E. Aleppo 255,655 185,000 111,791 99,903 93,553

E. Hama 7,358

E. Homs 12,052

N. Homs 39,769 33,049 29,638 25,760 30,209 28,937 12,834 30,097 29,105 26,766 2,071 23,273

Al Badiya 21,348 19,318 16,387

Jarablus 14,973 14,072 13,250 13,877 13,110 12,313

Tell Abiad 26,199 25,157 23,775

Total 1,523,927 571,736 631,498 556,944 477,324 87,475 82,677 12,834 50,896 43,947 42,215 39,079 2,071 23,273

Table 10 : No. of vaccinated children for each campaign and round

Table 9 : No. of targeted children for each campaign and round 3.1 Vaccination Activities



Governorate / Area

R12 MR AIRI 1/ OPV

AIRI 1/ Penta

AIRI 1 /MR

AIRI 2 /OPV

AIRI 2 /Penta

AIRI 2 /IPV

AIRI 2 /MR

AIRI 3 /OPV

AIRI 3 /Penta

AIRI 3 /MR

Vit A / Blue Cap

Vit A / Red Cap

Aleppo 97%

Idleb 103%

Lattakia 113%

Hama 95%

Ain Al Arab

(Kobani)84% 78% 80%

Al-Hasakeh 107%

Ar-Raqqa 102% 91% 97% 82% 72%

Deir-ez-Zor 102% 91% 95% 90% 82%

E. Aleppo 106% 85% 99% 91% 92%

E. Hama 83%

E. Homs 93%

N. Homs 90% 84% 79% 83% 82% 95% 83% 82% 82% 57% 80%

Al Badiya 85% 79% 72%

Jarablus 74% 72% 73% 84% 82% 83%

Tell Abiad 93% 92% 94%

Total 102% 89% 96% 87% 80% 84% 82% 95% 84% 83% 82% 82% 57% 80%

Table11 : Coverage percentage for each campaign and round

Figures 19, 20: TOT training _ AIRI 1

B. Supervisions and Trainings:EWARN team has effectively contributed to campaigns through staff trainings i. At the central level - TOT in Gaziantep:

EWARN response team participated in training the central vaccination team in Gaziantep in all cam-paigns (total number) including diseases surveillance, AEFI surveillance and reporting mechanism to the central level.

ii. District Level - vaccination field staff trainings:- The trainings were held by EWARN DLOs on AEFI surveillance through immunization campaigns.- Design special AEFI surveillance forms : Zero reporting – Investigation form.- Communication with AEFI doctors, supervise vaccination centers, and monitor the AEFI surveillance system.- Conducted daily staff performance monitoring during vaccination campaigns by the central vaccination team, WHO and UNICEF. - Will participate in the Routine Immunization Program TOT training to begin in early of 2017.

Figure 21: Homs polio campaign R1 Figure 22: Cold chain management training

C. Logistics:Due to the sensitivity of vaccines to temperature changes, the lack of infrastructure in Syria, and different controlling forces, the EWARN team has a role in tackling the difficulties to store and ship the vaccines by providing the proper trained staff in all areas of vaccine management.

- A series of trainings held by UNICEF were conducted concerning vaccines' shipment, storage, warehouse control and management. The CLOs were well trained and then they transferred their experience to field and vaccination staff to manage the logistic process safely.- A cooling warehouse has been established with sufficient capacity, to store supplies with a high quality and efficiency to support the routine vaccination campaigns in northern Syria. In addition, staff prepares the needed paper forms used for monitoring storage, shipment, and consumption. - Training on vaccine management. Due to EWARN’s good reputation, the staff was able to coordinate with and get approvals from controlling parties for shipment of supplies to hard reach and besieged areas. - Monitoring the quality of vaccine storage in sub-stores and vaccination centers during the campaigns, with continuous trainings to reduce wasting and improve quality and efficiency and increasing the safety of vaccination process.



Figure 26:Switching process

D. Social mobilization: Increase of community awareness on importance of vaccinating the children is a corner stone in EWARN strategies, however a great deal of extra efforts is needed to improve community awareness further to reach high coverage rates.At the end of each campaign an evaluation is completed to ensure that the community understood the correct message through culturally appropriate IEC materials distributed to all areas in Syria. Social mobilization activities were planned to promote the vaccination campaigns via advocacy meet-ings, conferences, lectures and children parties or other activities.

Figures 23, 24, 25: Social mobilization materials

E. Switching from tOPV to bOPV:One of the most difficult challenges was the switch process from tOPV to bOPV. Eventually the switch process was accomplished successfully due to great collaborative efforts between the EWARN team and other partners Especially WHO and UNICEF. A specialized training on the switch process was con-ducted on 05/12/2016, which was then replicated to the coordinators in the field. All tOPV in stocks were estimated and taken out of the cold chain.

The switch process was implemented through DLOs and FLOS who traced tOPV supplies and man-aged to transfer the stocks in all facilities. Some tOPV quantities were found in Ain Al Arab (Kobani) and Dar’a, which were transferred and disposed of on 08/08/2016 in accordance with UNICEF and WHO protocols. Adequate quantities of bOPV have been secured based on the vaccination needs in northern Syria.

Figure 30: WASH activities coverage in 2016

a. Security issues: the vaccination centers have been targeted many times by the air strikes where many vaccination staff have lost their lives including vaccinators and supervisors.b. Logistic aspect: late vaccination shipments and delivery due to delayed permission to cross the contact lines between the different control parties. In addition more risks were there during the shipment process.c. Shortage of health facilities due to recurring damage has resulted in the decreased ability to carry out the routine vaccination program , same applies to cold chain equipment which impacts negatively the immuniza-tion program.d. Shortage of cold rooms in some areas, where UNICEF has secured about 20 cold rooms but still unable to be shipped to inside Syria (only two rooms are installed inside)

2017 plan:

Challenges:

1. UNICEF will conduct high quality training in different areas of vaccination program including technical aspects; logistics; social mobilization and data analysis.2. Recruit more staff to manage the increasing workload.3. Effective communication and attempt to get permanent permission from Turkish government to cross Turkish – Syrian border to facilitate supervision and logistic issues.

The WASH team was established on June 2013; at that time the program has focused on: - Drinking water quality - Staff training (chemical and biological testing) using portable water testing devices- WASH responded to polio outbreak in Deir-ez-Zor in 2013 through implementation of control activities particularly monitoring of water quality. Reports of WASH continued to be published since then. Later in 2015, WASH team expanded to cover 8 additional governorates.- WASH reports are linked to water borne diseases reports.- More WASH staff was recruited to cope with system expansion under EWARN (20 staff member at field level + 2 in Gaziantep)

3.2 WASH (Water, Sanitation and Hygiene)



Figure 31: Water chemical testing in field

Figure 32: NGOs training about Cholera - WASH aspect

Figure 33: TOT training for WASH field officers

Essential tasks of WASH:1. Monitoring the quality of drinking water through chemical and biological analysis. Special laboratory are being used at central and peripheral levels. 2. Reporting about drinking water sources every two weeks to describe the chlorination status (yes/no), method of chlorination (gas / liquid / powder or tablets) and the materials used (Sodium hypochlorit

– Chlorine - Calcium hypochlorite).3. Combine all water quality testing reports to issue the bi-monthly WASH Bulletin.4. Monitoring water contamination, through the field monitoring team.5. Monitoring the household waste management highlighting the danger of its effect on health. 6. Collaborating with EWARN health team to compare findings from WASH and alerts of WBDs of EWARN. 7. Conducting awareness campaigns in highly populated areas with high incidence of waterborne diseases (education about methods of household water treatment and safe storage (HWTS). 8. Raising alerts about high risk WBDs areas (especially suspected cholera cases) .9. Building capacity of WASH Field staff in Syria.

Goals and work strategies:- Ensure safety of drinking water. (Assigning teams for investigation and monitoring of water sources and respond activities) - Create Water-Map (Carry out drinking water source surveys, documenting data on maps).- Plan response activities: (Determine the needed activities in response to waterborne disease, which are: Other Acute Diarrhea– Acute Bloody Diarrhea– Acute Watery Diarrhea - Severe Typhoid Fever– Acute Jaundice Syndrome– Leishmaniasis– suspected Cholera), and raising alerts when needed.- Establish coordination mechanisms with all WASH organizations inside and outside Syria.

Implemented activities:- In collaboration with UNICEF, an evaluation of drinking water sources in 10 governorates within 3 months (February– April 2016). - A water quality evaluation with Ihsan Organization in Idleb and Hama (June).- Develop a waterborne diseases training project for health workers in Idleb (especially cholera) with SEMA.- Biological drinking water testing project with SEMA o in Idleb and Hama, over a four-month period (August-- November).

Challenges:

1- Adding new field officers to expand the coverage of WASH services, as follows:

Future plan:

2- Secure procurement of laboratory equipment (chemical and bacterial): to keep on chemical and bacterial tests; ensure water chlorination process, thus to observe the pollution where it may exist.3- Secure procurement of chemicals and chlorination materials and reagents (such as: free chlorine reagent - multiple forms of chlorine quantities Liquid, Powder and chlorine pills).4- Conduct workshops and training activities for the new staff, to build up their experience and issue quarterly reports with recommendations and proposals to improve the works process.5- Conduct awareness campaigns in high risk areas and participate in response activities in the area.6- Continue preparing water and sanitation rehabilitation project studies, develop plans and implement

Place of work No. 2015 No. 2016 EstimatedNo. 2017 Total

Gaziantep / Central team 1 1 Assistant 1 Data entry 3

Aleppo 2 3 3 8

Idleb 4 0 0 4

Lattakia 1 0 0 1

Hama 1 0 0 1

Deir-ez-Zor 1 0 0 1

Ar-Raqqa 1 1 1 3

Dar'a 1 0 0 1

Quneitra 0 0 0 0

Homs 0 1 0 1

Rural Damascus 0 1 0 1

Al-Hasakeh 0 3 1 4

Total 12 10 6 28

Difficulty accessing some areas due to the change of control forces.

Since EWARN has started in 2013, the progress achieved has been great and continue to improve over time. The basic simple functions of EWARN is regularly and efficiently practices and now the program is shifting towards stability. As the epidemiological laboratory is a corner stone in any surveil-lance program, the idea is to have a national laboratory system with rea-sonable diagnostic capacity , as well as improving the quality of surveillance by timely confirmation of any outbreak to allow rapid response and limiting its spread.The first referral laboratory was established in western rural Aleppo- At-areb at the beginning of 2015 with a grant from the Italian government, to confirm measles, rubella and HAV using ELISA. At the beginning of 2016 the lab added culture services to test stool samples for Salmonella and cholera. Also in 2016, WHO provided equipment for two other laboratories , one in Idleb and the other in A’zaz , but unfortunately due to the unstable security situation these labs ae yet to be functional. Figure 34: Stool culture incubator

Table 12 : WASH field officers by governorate in 2015 , 2016 and 2017 plan

3.3 Laboratories and specimens shipment:



A. Referral Laboratory:Considered a supportive element of the EWARN .The functions of Surveillance laboratories- Timely laboratory confirmation of disease pathogens for surveillance- Training and continuous education for laboratory personnel on laboratory techniques, use of equipment, and appropriate and safe collection, storage and transportation of specimens- Strengthened rapid response to outbreaks through timely testing of specimens and identification of the causative agents and ensuring the capacity to process a large volume of specimens in an emergency- Coordination and promotion of quality assurance programs

Others Functions :- Training of laboratory technicians/technologists in diagnostic techniques & bio safety procedures.- Training of staff on specimen collection, safe handling, storage and shipment to the laboratory.- Collection, compiling, analyzing, sharing and disseminating laboratory data with other laboratories, and other concerned partners

Figure 35: Idleb Laboratory

Referral laboratory service delivery system:

Through cooperation with field NGOs, EWARN referral labs receives the samples (blood, serum, stool, …) collected by the DLOs and dispatched to the lab by a trained logistician. After the samples are received by the lab, quality is ensured and testing is started according to a set time frame so that the results are shared in a timely manner for the weekly bulletin.Regular supervisory visits (whenever possible) from the central team to the labs on regular basis are used to review staff performance and update the staff of any new technologies.The laboratory working hours are from 09:00-17-00, Saturday to Thursday.All the tests with the investigation forms and lab requests are documented with the results in both hard and soft copies.

- Tests diseases that can be vaccine-preventableMeasles IgM - Rubella IgM - Mumps IgM - HBsAg

- Water-borne diseases TestsHAV IgM-HEV IgM

- Bacterial culture testsStool culture for: Typhoid fever, Shigellosis, Vibrio Cholera - Blood culture: (coming soon)

- Hepatitis viruses (Blood Bank)HBs Ag-HCV Abs- HIV Abs

- Immune testsPCR (coming soon)

- chemical and blood testsLiver functions - Renal functions - Complete Blood Count

- Others Sputum examination for TB - Gram stain for Malaria and Leishmaniasis

Table 13 :The available tests in EWARN Laboratory

Figure 36: Stool culture for STF case Figure 37: Serum samples for STF outbreak investigation

Training and coordination:- Update and disseminate the laboratory guidelines.- Perform sero-survey for HBV in 250 health workers/ Bab Alhawa Hospital – Idleb.- Safety testing for blood supplies at the Atareb blood bank. - Cooperate with private laboratories, hospitals and clinics for viral testing or confirming the findings of the tests performed in inaccurate methods.- Evaluating the needs of epidemiological laboratory in Harim supported by IMC.- Training the technical staff of other laboratories on the usage of some RDTs (Leishmania visceral, cholera RDTs, Zeil-nilson dye).- Two laboratories were donated by WHO to EWARN (one in Idleb city and the other in A’zaz).- A proposal was sent to WHO ( in 2016) to establish a new laboratory in Tell Abiad.- Two proposals for another laboratory were submitted to GIZ and the Italian government to establish a lab in southern Syria (Dar’a, Quneitra).



Disease Test # tests # +ve Results % -ve Results

Measles Measles IgM 198 75 23

Rubella Rubella IgM 117 0 117

Hep A Hepatitis A IgM 451 311 140

Hep E Hepatitis E IgM 225 6 219

Hep BHBV Ag 1549 207 1342

Hepatitis B IgM 250 144 106

Hep C Abs HVC 1298 78 1220

HIV HIV (1&2)Abs 1044 4 1040

Typhoid FeverSalmonella IgM 465 159 306

Stool culture for Salmonella 7 0 7

Suspected Cholera Stool culture for Vibrio cholera 5 0 5

Mumps IgM Mumps 112 53 59

T.B Zeil-Nelson, AFB 12 1 11

Visceral Leishmaniasis Chromatography 1 1 0

Grand Total 5978 1084 4894

Table 14 : The performed tests EWARN Lab during 2016 B. Specimens Shipment:

- Training the field staff on the proper methodology of collecting, handling and shipping the specimens. In addition to distributing the related guidelines.- Equipping the DLOs with the needed means for specimens’ collection, preserving and shipping (refrigerators, generators, containers, ice packs, …), in addition to transporting mediums for cholera and RDTs.- Recruiting logisticians for samples shipment from the field to the lab and to Turkey for AFP samples. - Designating specific stoppage points to store the samples – if needed- provided with the proper cold chain equipment. - Strict follow up on the sample movement by the central level. - Arrangements were made with the Jordanian ministry of health to receive AFP samples from the southern governorates through WHO office in Amman. Follow up is ongoing.

Challenges:

1. Lack of funding and logistical support for laboratory issues in general2. Poor infrastructure, electricity problems and lack of basic equipment and consumables.3. Scarcity of the qualified trainers and training activities in the lab field and qualified technicians for maintenance of the equipment. 4. Unavailability of Universal control. 5. Border problems (documentation and security ) that leads to delay or inability to ship the materials 6. Lack of fund to upgrade the available equipment.

Figure 38: Specimens Shipment through Jordan

PHOTO @EWARN TEAM



Future Plans:1. Activate the labs in Idleb city and A’zaz .2. Equip the labs in besieged areas with the basic package for outbreak confirmation in order to take the needed steps for response.3. Activate Real Time- PCR and the blood culture.4. Explore financial support for continuous training in immunology and macro-biology field to include this field in our scope of tests.5. Increasing the capacity of EWARN lab staff inside Syria.6. Provide refresher safety procedures training.7. Continue to provide regular maintenance of current lab equipment and ensure back-up equipment is available to continue functionality of the lab.

Figure 39: Specimens Shipment through Turkey borders

Through two years , the program has achieved significant progress in epidemic diseases and outbreaks surveillance, there is a large amount of epidemiological data, which led to an urgent need to set up the rapid response system for any potential outbreak.This goal will be achieved by a plan through: Organizing logistics and a rapid response team.

I. Rapid Response:- Rapid response team (RRT) is formed, defining the functions and responsibilities of each member; TORs will be updated regularly (every 6 months ). Six EWARN team members have been trained and assigned to high risk areas (camps - besieged areas – areas where water sources are contaminated).- Prepare outbreak response plans (including standard case management plans) to control the outbreaks and epidemics, and updating them according to the situation.- During 2016, more than 48 response missions have been performed, with the proper field procedures : water sources samples - cases sampling to confirm the outbreak and determine the

infection source - water treatment procedures - hygiene and awareness campaigns for health work-ers and community leaders - providing the needed medications for proper case management - dis-seminating IEC materials for the public and health workers - follow up the trends after the imple-mentation and finally issuing the detailed reports about those activities.

Outbreak /Alert Epi-Week Governorate District

Labsamples Water

samples

Response

Blood school drugs WASH IEC Coordination :NGOs / partners

OAD 8 Aleppo A’zaz No No Yes No Yes Yes Mercy corps

Leish 11 Idleb Idleb No No No No No Yes MENTOR

Mumps 13 Idleb Idleb Yes No No No No Yes

Mumps 15 Aleppo A’zaz Yes No No No No Yes

Lice 17 Ar-Raqqa Tell Abiad No No Yes No Yes

Chicken pox 19 Ar-Raqqa Tell Abiad No No No No No Yes

OAD 19 Aleppo A’zaz No No Yes No Yes Yes MRFC - Camp management

STF 20 Idleb Harim Yes No Yes No Yes Yes Bihar

STF 20 Idleb Idleb Yes No Yes Yes Yes Yes Goal

OAD 20 Rural Damascus Qatana No No No No No No

AJS 21 Damascus Damascus Yes No Yes Yes Yes Yes

OAD 22 Rural Damascus Duma No No No No Yes Yes Provincial Council

AJS 24 Rural Damascus Rural Damascus Yes No Yes Yes Yes Yes Health Directorate - Local Council

Pertussis 25 Deir-ez- Zor Abu Kamal No No Yes No Yes

Chicken pox 25 Deir-ez- Zor Abu Kamal No No Yes No Yes

Pertussis 26 Deir-ez- Zor Abu Kamal No No Yes No Yes

ABD 27 Al-Hasakeh Ras Al Ain No No Yes No No Yes

STF 27 Dar'a Dar'a No No Yes Yes Yes Yes SAMS- Local Council

ILI 28 Aleppo Afrin No No No No No Yes

STF 29 Idleb Idleb Yes No Yes No Yes Yes Idleb drinking Water Directorate

AJS 29 Idleb Idleb Yes No Yes No Yes Yes Idleb drinking Water Directorate

OAD 30 Idleb Jisr-Ash- Shugur No No Yes No Yes Yes SEMA – Acted

STF 31 Idleb Idleb Yes No Yes Yes Yes Yes Local Council

STF 31 Idleb Al Ma’ra Yes No Yes Yes Yes Yes

STF 31 Idleb Al Ma’ra Yes No Yes No Yes Yes

AJS 32 Idleb Harim Yes No Yes No Yes Yes Camp management -Idleb drinking Water Directorate

STF 33 Dar'a Dar'a No No Yes No Yes Yes

STF 33 Homs Homs Yes No Yes No Yes Yes Drinking Water Directorate

AJS 36 Aleppo A’zaz Yes No Yes No Yes Yes Mercy corps - Camp management

Meningitis 36 Rural Damascus Az Zabdani No No No No No No

STF 36 Dar'a Izra' No No Yes Yes Yes Yes Local Council

AJS 36 Dar'a Izra' Yes No Yes Yes Yes Yes Local Council- Yakin Media orga-nization

OAD 37 Idleb Jisr-Ash- Shugur Yes No Yes No No Yes

Guillain-Barré

syndrome39 Rural Damascus Az Zabdani No No No No No No

Hemolysis cluster 39 Aleppo Jebel Saman No No No No No Yes Local Council

STF 40 Idleb Harim Yes No Yes Yes Yes Yes

STF 40 Idleb Jisr-Ash- Shugur No No Yes No Yes Yes

LICE 41 Idleb Idleb No No No Yes No Yes QRC

AJS 41 Aleppo A’zaz Yes No Yes No Yes Yes Mercy corps- IDA-IHH

Scabies 43 Quneitra Quneitra No No No Yes No Yes Injaz for development Organization

AJS 44 Aleppo Afrin Yes No Yes Yes Yes Yes Kurdish Red Crescent

LICE 46 Idleb Idleb No No No Yes Yes Yes QRC

MUMPS 47 Aleppo Jebel Saman Yes No No No No Yes

STF 48 Quneitra Quneitra No No Yes Yes Yes Yes

STF 48 Quneitra Quneitra No No Yes Yes Yes Yes

AJS 48 Dar'a Dar'a Yes No Yes No Yes Yes Local Council

Mumps 47 Aleppo Jebel Saman

Table 15 : Review of Outbreaks / Alerts investigation details with the related response activities _ 2016

3.4 Response and related Logistic activities:



Figure 45: STF response inTah – IdlebFigure 44: AJS investigation inHrak – Darà

Figure 41: STF investigation in Atmeh camp - IdlebFigure 40: STF awareness in Tal Dahab - Homs

Figure 42: STF response in Sahm AL Jolan – Darà Figure 43: AD awareness in Azaz camps – Aleppo

Figure 46: UCE (acute hemolysis) investigation in Aleppo city

Figure 47: Lice and Scabies investigationin Afis camp - Idleb

Figure 49: AJS awareness in Azaz camps – Aleppo Figure 48: SARI investigation in Atmeh camps – Idleb

II. Organizing logistics:- Establish warehouses to store response supplies such as: : medicines, IEC materials and necessary supplies to be utilized in outbreaks (including cholera kits).- Increase number of the warehouses from 2 (in 2015) to 6 warehouses in: Idleb, Aleppo , Darà , Homs, Ar-Raqqa and Rural Damascus . - 10 cholera kits are available and prepositioned for any potential cholera outbreak in the north. The IDDKs are distributed as shown in Table 16 below (IDDK10 deleted from the list as it was in Aleppo city before the evacuation).- Receive and transfer referral surveillance laboratory in northern Syria.- Provide field level teams at field level needed logistic supplies to support their work (a generator, laptop, satellite internet, mobile phone, printer, cold chain equipment for samples-refrigerator, reliable electrical and normal cold box containers to transfer samples).- Support the samples transfer and logistics services in Syria via recruiting a vehicle.

DDK No. Expiration Date Condition of the Kit (*complete, incomplete)

LOCATION

Governorate Warehouse

DDK 1Drugs: Aug 2018 - ORS : 2020

Complete

Idleb Sarmada

DDK2

DDK 3

Drugs: Aug 2017 - ORS : 2020DDK 4

DDK 5

DDK 6 Drugs: Aug 2018 - ORS :2020

Aleppo

AfrinDDK 7

Drugs: Aug 2017 - ORS: 2020DDK 8A’zaz

DDK 9

* Complete : the kit is sealed and unbroken - Incomplete: Kit is not sealed, with missing things inside

1. The deteriorating security situation throughout the north.2. Some areas are harder to reach because of the bomb attacks or fighting.3. Inaccessibility to some areas.4. In some areas laboratory services do not exist.

Future plan:

Challenges:

1. Expand the response team, especially in eastern areas (Deir-ez-Zor - Ar-Raqqa – Al Hasakeh).2. Allocate a proper space in the health institutes to isolate and manage the infected cases.3. Support the warehouses management and supplies to ensure supply levels are sufficient for a quick response. 4. Strengthen the collaboration and coordination among organizations involved in epidemics response.

Table 16 : IDDKs status details in EWARN warehouses

SECTION 4 : BUILDING CAPACITY AND ADVOCACYAnnual Technical Report for Early Warning and Response Network



SECTION 4 : BUILDING CAPACITY AND ADVOCACYAnnual Technical Report for Early Warning and Response Network

Training is an essential cornerstone in EWARN, with a vital objective in order to strengthening the surveillance and response system (EWARN) for communicable disease in Syria through capacity building of EWARN and NGO staff, and including awareness raising within both the local communities and among health workers on communicable disease prevention.

Donors funded the training during 2016:1. BMGF2. WHO: funded relevant activities the 1st half of 2016.3. SEMA: supported FLOs training in Idleb on water borne diseases (in between 1st July to 30th November 2016).

Training

Figure 54: Training categories in EWARN

# Goal Titles No .Trainees Facilitator No. of sessions Time

1st

Sensitize the healthworkers to the diseases with highly outbreak possibilities

EWARN overviewCase definitionAFPInfluenza

229 DLOs 19 Jan - Feb

2nd

Alert notificationZero reportReporting mechanism Cholera

259 DLOs 20 Apr - May

3rd

Case definitionZero reportReporting mechanismInfluenza

251 DLOs 20 Nov

Table 17 : NGOs / Health works training sessions in 2016 :

Governorate District Estimated No. No. of Attendees Date

Idleb

Idleb 15 14 27/1/2016

Harim10 8 28/1/2016

10 10 31/1/2016

Idleb 15 16 28/1/2016

Al Ma'ra

10 11 30/1/2016

15 15 27/1/2016

10 10 24/1/2016

Lattakia Lattakia 10 13 27/1/2016

Ar-Raqqa Tell Abiad 10 11 29/1/2016

Dar'aIzra' 15 16 27/1/2016

Dar'a 15 16 28/1/2016

Aleppo

Afrin 15 15 27/1/2016

Jebel Saman

10 9 27/1/2016

10 5 28/1/2016

14 16 2/2/2016

Ain Al Arab 10 11 29/1/2016

Al- Hasakeh Quamishli 10 10 31/1/2016

Rural Damascus Rural Damascus 10 6 31/1/2016

Homs Ar Rastan 15 15 28/1/2016

Total 229 229

Figure 55: 1st NGOs health workers training

Table 18 : 1st NGOs health workers training details

4.1 Building capacity



Governorate District Estimated No. No. of Attendees Date

Idleb

Idleb 15 14 27/4/2016

Jisr-Ash- Shugur 10 13 25/4/2016

Harim10 11 27/4/2016

10 22 28/4/2016

Idleb 15 12 26/4/2016

Al Ma'ra

10 10 4/5/2016

15 17 30/4/2016

10 10 25/4/2016

Lattakia Lattakia 10 10 29/4/2016

Ar-Raqqa Tell Abiad 15 21 28/4/2016

Dar'aIzra' 15 17 28/4/2016

Dar'a 15 15 10/5/2014

Aleppo

Afrin 10 12 27/4/2016

Jebel Saman

10 8 25/4/2016

0 18 23-24/4/2015

0 6 15/5/2016

Ain Al Arab 10 8 1/5/2016

Al- Hasakeh Quamishli 10 9 29/4/2016

Rural Damascus Rural Damascus 10 4 14/5/2016

Homs Ar Rastan 15 22 25/4/2016

Total 229 259 Figure 58: 2nd NGOs health workers training

Figure 56: NGOs / Health works trainingin Aleppo Figure 57: NGOs / Health works traininginIdleb

Table 19 : 2nd NGOs health workers training details



EWARN staff trainingsessions in 2016:

A. Central Level officers training:

Figure 59: Epidemiology and outbreak in emergency training

Figure 60: Communication skills training

EWARN training for NGOs



# Goal Titles No .Trainees Facilitator No. of sessions Time

1st

Refresher course on the basic field epidemiology and outbreak investiga-tion/response

Epidemiology for Disease Control in EmergenciesElectronic Reporting SystemField Epidemiology ProtocolsInformation Management in emergenciesPreparing an outbreak investiga-tion ReportQuantitative Indicators

WHO 10 27th – 28th Jan

Gaziantep - Turkey

2nd Improve communication skills

Active communicationNegotiation Presentation skills

European Business Center

12 25th-26th Mar

Istanbul - Turkey

3rd

Improve training and presentation skillsMaximizing the transfer of knowledge and skills to the trainees in a given time

Training Concepts and planningDeliver Training (Presentation skills)

European Business Center

11 11th- 12th July

Istanbul - Turkey

B. District Level officers and Rapid Response team training:

# Titles Facilitators Trainees No. Place Date

1st Basic field epidemiology and outbreak inves-tigation /response

WHO / CLOs 10 Turkey 26th -29th Feb

DLOs 9 Syria 10th – 12th Mar

2nd

Review of Acute Flaccid ParalysisOutbreak investigations, response and reportingCase Definitions – Updated Alert verification processData Management and Analysis – VPDs/VBDs/WBDsMeasles surveillance, challenges and way forward Introduction to Nutrition surveillanceSIG IntroductionExcel basics training

WHO / UNICEF / CLOs 4 Turkey 4th – 6th May

CLOs 16 Syria 13th- 15th May

3rd

Review 0f Acute Flaccid ParalysisVAPP &VDPVDefinitions Events & OutbreaksResponse to post-switch detection of WPV2Measles surveillance updateOther VPDs surveillance updateAlert Summary ToolRecommendations to improve data flow

CLOs /BMGF consultant 13 Turkey 27th – 30th Sep

4rd

Review of AFP - Surveillance of SARI and ILIVPDs surveillance update - Measles indicators Introduction to SIG : Social mobilization-Vac-cination logistics - The importance of surveil-lance in the planning for EPI program The importance of AEFI surveillance in the vaccination campaignsVisceral leishmaniasis ODK Form Collection

CLOs /BMGF consultant / MENTOR 11 Turkey 6th- 10th October

Figure 63:1st Quarterly meeting – Syria Figure 64:3rd Quarterly meeting – Turkey

Figure 61: 1st Quarterly meeting – Turkey Figure 62: 2nd Quarterly meeting – Turkey

Table 20 : CLOs training details _ 2016Table 20 : CLOs training details _ 2016

Table 21 : The details of quarterly Meetings _ 2016



C. Field Level officers training:

# Titles Facilitators Trainees No.

Sessions No. Place Date

1st

Severe Acute Respiratory IllnessMumpsMeningitisCholeraTuberculosisOutbreak Investigation steps

DLOs 118 18 Syria 7th – 20th Jan

2nd

Review of Acute Flaccid ParalysisCase definition refreshExercise on filling the weekly zero reportAWD Surveillance and standard case managementDisease Surveillance in EmergenciesField Epidemiology Protocols

DLOs and WASH Officers 133 20 Syria 7th -30th Apr

3rd

Cholera (general overview, Intervention Strategies, Clinical Aspects/Case Management, Surveillance/Data Collection/Indicators, Sample Collection, Wat San Strategies/IEC) Typhoid feverAcute jaundice syndromeAcute Bloody DiarrheaGuidelines in Water Quality Assessment

CLOs /BMGF consultant 13 Turkey 27th – 30th

Sep21st Jul - 3rd

Aug

4rd

Case definition - Review of CholeraTyphoid feverAcute jaundice syndromeAcute Bloody DiarrheaField Epidemiology Protocols Outbreak Investiga-tions and Response

DLOs and WASH Officers 139 20 Syria 2nd Oct - 3rd

Nov

Figure 65: FLOs training - Al Hasakeh Figure 66: FLOs training - Idleb

Figure 67: 3rd FLOs training

Table 22 : The details of FLOs trainings _ 2016

New staff training:

Table 23 : New staff training details in 2016

Governorate District Specialty Trainees No. Facilitator THE DATE Titles

Aleppo Jebel Saman Lab Staff 2 CLO 11th Feb

Case definition Acute Flaccid paralysis surveillanceTuberculosisSevere Acute Respiratory IllnessOutbreak InvestigationsMumpsMeningitisCholera

Idleb Idleb

FLOs

2

DLOs 4th – 15th May

Dar'a Dar'a 2

Aleppo A’zaz 5

Figure 68: Lab staff training - Aleppo Figure 69 : New FLOs training – Dar`a

1- Borders closure obstructs training sustainability.2- Serious security situation impedes moving between targeted areas.

2017 Plan:

Challenges:

1- CLOs training: very important and required to improve the skills of central level members especially for bio statistics, mapping, and deeper epidemiological analysis. 2- Continue building capacity for health workers through the implementation of quarterly meeting training in Syria to train all employees in EWARN, as well as the NGOs workers. 3- Quarterly meeting, FLOs training and NGOs training should be conducted four times within the next year.4- Health workers in private clinics training: important to increase the sensitivity of EWARN in the detection of cases of acute flaccid paralysis and other communicable diseases that are not declining health centers and hospitals.



i. In Syria

Place Targeted NGO / Partner Goal Attendees

No. Related activities Date

Aleppo city

Space of HopeDarna Center (Basmeh & Zeitooneh)ShafakIMC

Health awareness campaign about Cholera and water treatment procedures

60

2 days workshop, 2 weeks campaign target-ed schools and2000 families, 10.000 IEC disseminated

24th and 25th May

RuralDamascus

Unified Medical Office

• Introduce EWARN,• Have an overview on Health Facilities reporting to EWARN• Overview on Facilities of EWARN • Strengthening relationship

8 3rd Sep

Daraà : Izra` , Nawal - Quneitra

Health Directorate and health work-ers in Darà and Quneitra

Introduce the EWARN health workers in Dar’a hospitals and health directorate, to work with EWARN and re-port the epidemic diseases.

72

Presentations about EWARN and case defini-tion,Reporting mechanismCooperation mechanisms

25th -26th

- 28th Jul

Figures 70, 71: Advocacy activities in Darà and Quneitra_ Syria

Good relationship with NGOs and local authorities is essential to success the work in EWARN and facilitate the staff work. Therefore, several advocacy meetings were convened in Syria to strengthen the relationship between EWARN and other organizations.

Table 24 : Advocacy activities details _ Syria

- Future plan:Continue to organize more advocacy activities especially in Syria, with focus on \ organizations not currently part of the network in order to strengthen the relationship and improve EWARN reporting.

ii. In Turkey

As part of the EWARN Syria policy to cooperate with all the actors in the field, continuous meetings with differ-ent actors were held in Turkey throughout 2016This activity was reactivated recently in order to inform the partners about the EWARN surveillance system, how the bulletins and reports are developed, and how such tools can be in planning health projects in Syria. Two meetings were held with PAC and QRC (on 21st September and 1st October respectively).

4.2 Advocacy:

SECTION 5: THE DATA MANAGEMENT TEAM (DMT)Annual Technical Report for Early Warning and Response Network



SECTION 5: THE DATA MANAGEMENT TEAM (DMT)Annual Technical Report for Early Warning and Response Network

DMT is considered the web that links the departments with each other, fully involved in every single EWARN activity or mission, guiding the technical officers from the planning phase, through analysis, proper visual-ization to reporting and information dissemination phase. The team is highly committed to provide essential high quality data in a timely manner, technical support and capacity building for the entire team to enhance computer skills and assist in finding proper solutions for the encountered challenges.The DMT takes into account the importance of the knowledge exchange fostered at the central level and is open to learned experiences of others.

1. Software:

A variety of softwares are used for specific purposes such as data entry, analyzing visualization and reporting. The current softwares :

- Microsoft Office Pro 2016, Microsoft Office 365 and Prezi- ArcGIS, QGIS and ArcGIS online- Adobe Package- SQL Server and Visual Studio- Open ODK Collect, Power BI and Tableau- Information for Action (IFA) for AFP surveillance- Emergency Nutrition Assessment (ENA) software for SMART

2. Data Flow

The major official measure of receiving data is the electronic mail, while we also use Skype, WhatsApp and phone calls to communicate back and forth with field.Data is submitted to DMT in two ways:

1- Immediate reporting: In case-based surveillance, where the forms of the investigated case are received immediately (from FLO, DLO or the health worker to the CLO).2- Regular reporting: The weekly zero reporting, where the FLO submits the data to the DLO, and the DLO in turn submits the data to the CLO. Another example the bi-weekly data of WASH depart ment, where the WASH officer submits the data to the CLO.

- Two Data specialist joined- MS Excel forms were extensively used instead of MS Word forms .- Information for Action (IFA) software, provided by WHO, was utilized to record the Acute Flaccid Paralysis cases.- Designing the maps using GIS software (prior 2015 Adobe Photoshop was used to generate maps).- Uploading all products on ACU website, to be available and accessible for everyone at any time.

2016 Highlights:

2015 Highlights:

- Developed many tools to study the syndromes, and to get summaries efficiently. - Focused on strengthening the electronic filing system at the CLO level. - Emphasis to generate interactive maps and to utilize new elegant tools such as Microsoft Power BI for data analysis and visualization and Open ODK for mobile data collection.

DMT current structureThe DMT specifies one member to support each surveillance section in particular, as follows:

- Epidemiological generic data- AFP - WASH and Nutrition- VPDs and Adverse Events Following Immunization

Implementation

3. Zero Report (ZR), Completeness and Timeliness

A well-structured MS Excel form was developed to collect the syndromes’ numbers. The new form is one page, user-friendly and includes data validation rules and some structures to get the cases and the alerts as records

(Figure 72).

After finalizing the coding of the health facilities, we embedded the encoded HFs in the ZR form, so that we are able to track any changes in number of HFs on weekly basis.The Epi-week ranges from Sunday to Saturday, so if the ZR is received between Sunday and Monday 5:30 pm next week, it will fall under the timeliness indicator for the current week, otherwise it will be considered in the completeness indicator only (Figure 73).The team developed a subtle mechanism to track receiving of weekly ZRs, so we can identify the completeness and time-liness by even the HF level at any week.

Figure 72: The new form of ZR, the alert’s type and threshold are colored in red.

Figure 73: The data flow of ZR in one week



Figure 74: shows the completeness and timeliness for all the health facilities by week through 2016

4. Alerts

Based on the ZR database, DMT developed a methodology to figure out of alerts in any syndrome. This information along with the proportional morbidity is circulated to CLOs on weekly basis, thus the required response can be carried out in such situations timely.

5. Health Map

Every HF has a unique code based on the exact location based on official Syria gazetteer (a geographical dictionary; book in which a subject is treated especially about geographic distribution and regional special-ization) provided by OCHA. For those communities not covered by OCHA, we encoded them by ourselves. While for the visualization purposes, we tend to use the closest community coded by OCHA.

At any week, if a new HF starts reporting, it will be added and coded as of the same week of reporting. Where-as if the health facility does not send their report, it is addressed with a justification. However, if the HF stops reporting for any reason like being destroyed or for security constrains, it will be filtered out from the HM(Figure 75).

Figure 75: The list of coded HFs, with an indication to one of the HFs stopped reporting

6. Active Surveillance (AS)

In 2016, intensive follow up with the AS sites’ visits was conducted on a weekly basis. The data is compiled accumulatively for the sake of required comparisons among time periods.When the coded HFs are used, AS indicators are continuously produced, that link this indicator with zero reporting and with the related AFP indicators (Figure 76).

Figure 76: Active Surveillance review in 2016

7. The Newly Proposed Bulletin Form

As a pilot, a well-structured tool is built using dynamic functions to utilize the ZR data, aiming to generate the needed summaries, graphs, tables and descriptive text (Figure 77).

In order to produce a one week bulletin, all what is needed is just appending the weekly refined data to the database, refreshing the summaries with one click, and picking the week number from a list; then the bulle-tin will be ready to be printed.

Figure 77: The proposed Bulletin Form



8. Information for Action (IFA) – the data management system for AFP surveillance

On March 2015, WHO provided the EWARN team with IFA, which is used to record all AFP cases to carryout proper analysis (Figure 78).

In IFA, most of the current surveillance variables and indicators are available, needing little adjustments to get knowledge of risk assessments and some other indicators.Concerning AFP, several tools were developed to implement multiple tasks, as follows:

Figure 78: IFA Software

9. Water Sanitation and Hygiene (WASH)

Many tools and forms were developed for collecting and working with data related to water quality and water stations’ infrastructure and sanitationThe essential tool is bi-weekly WASH bulletin which is generated using MS excel and ArcGIS. This report shows the indica-tors of the water stations and chlorination (Figure 79).

Figure79 : WASH Bulletin

- To generate the weekly AFP bulletin automatically according to the summaries of IFA.- To get a readable shape of the AFP line list based on IFA’s variables.- To summarize the essential indicators of the weekly review occurred with WHO consultants.

10. Nutrition

Emergency Nutrition Assessment (ENA) is used to ensure standardization of anthropometric measurements. Zero report, supervisory form and the other formats are MS excel files. (Figure 80 ).

Figure 80 : ENA Software



11. Summarization Tools of DLOs

With the aim of increasing accountability in analysis and data summarization at the DLO level, the DMT conducted many MS Excel trainings to build DLO capacity, and developed two summarization tools:

- VPDs summarization tool. - Alert and outbreak listing and summarization tool (Figure 81).

Figure 81: Alert and outbreak summarization tool

12. Data Visualization

In EWARN reports, the information is represented in both the analytical and descriptive way (tables, graphs, images, maps and text).In the fourth quarter of 2016, a strong structures for information is being created using MS Power BI, Tab-leau has started. In addition, ArcGIS online is used to generate interactive maps.

13. Data Archiving and Sharing Policy

At the CLO level, the files are stored on a local server and using Microsoft OneDrive for business and Office 365 SharePoint, in order to be able to access the files anytime and anywhere, which allows product avail-ability on the ACU website to all.

In terms of filing system, a lot of efforts were done to manage the old files and folders, and to prepare the files storing policy, and eventually to deliver this knowledge to the central team.In terms of information sharing, the regular products are shared using email with many partners like in-ternational and local NGOs, , medical associations, labs, …. etc. On the other hand, we share the detailed information upon request and as per needs.

1- One of the major challenges was encoding the HFs and the water stations. An enormous cleaning effort for the 2015 and 2016 databases was conducted, to eliminate the multi-spellings and wrong-spellings. The DMT struggled to find a proper approach or solution to track the zero reporting indicators. Eventu-ally, DMT overcame this challenge successfully by going through the data week by week , correcting the mistakes and filling the gaps.

2- A proper filing system is challenging, with such an enormous number of documents and data points fromthe beginning of EWARN in 2014 until the end of 2016, where a great deal of time and effort is needed to refine and structure the system.

3- The complete shift to data collection using smart phones requires a lot of tests and trainings at the field level.4- Providing time navigator in the interactive map is challenging.

2017 Plan:

Challenges:

1- In order to make data collection user-friendly and fast, the DMT intends to utilize smart phones data collection tools for both the immediate and the regular reports.2- The DMT intends to generate 100% automated bulletins for all surveillance sections.3- The DMT intends to utilize Power BI and Tableau intensively4- The DMT intends to design essential interactive maps for all surveillance sections, in order to visualize the information on the EWARN website in a well-organized and accessible manner.5- The DMT intends to enforce the storing and sharing policies extensively to have access easily on the archived data.

Recommendations

1- Deliver the data handling methodologies to the vaccination team to strengthen the relationship between the surveillance and the response systems.2- Intensify the coordination with the other departments of ACU, so the DMT can exchange experience with others. 3- Trying to find and establish other global-standard software for surveillance activities.4- The importance of providing data management basic trainings with certifications for both the central and the district levels.5- Emphasis on providing advanced data management trainings with certifications for the DMT.

SECTION 6: COORDINATION AND PARTICIPATIONSAnnual Technical Report for Early Warning and Response Network



SECTION 6: COORDINATION AND PARTICIPATIONSAnnual Technical Report for Early Warning and Response Network

Cluster / Group Frequency Place

Health cluster -Turkey`s Hub 2 weeks Gaziantep

WASH cluster-Turkey`s Hub 1 month Gaziantep

Nutrition cluster - Turkey`s Hub 2 weeks Gaziantep

Health cluster- Jordan`s Hub 6 weeks Via Skype

Atmeh Actors Group 1 month Syria - Atmeh

Cholera Technical Group 1 month Gaziantep

Table 25: Review of participation details for EWARN team in different sectors:

Coordinating Partner Area of coordination

BMGF Planning and implementation for E- SurveillanceTechnical support (Epidemiological expert recruitment) in the 2nd half of 2016

WHO

Technical support (Epidemiological expert recruitment) in the 1st half of 2016AFP surveillance and indicators supervision Vaccination activities supervision and related trainings Funding the training activities and guidelines printing in the 1st half of 2016 (through SAMS)Funding the vaccination campaigns (through UOSSM)Donation for 2 Laboratories in Idleb and A’zaz Donation for 4 IDDKs

UNICEF

Vaccination activities supervision and related trainings Supervising the switch process for polio vaccine(tOPV to bOPV)Funding social mobilization materials for AIRI (1,2 and 3) campaigns Providing cholera RDTs for both north and south of SyriaPlanning for the Nutrition surveillance program

Health Directorate _ Gaziantep Receiving samples of: AFP- suspected cholera – SARI

Health Directorate _ Amman

Receiving samples of: AFPPlanning to receive other kinds of samples (measles – rubella – cholera and SARI)

SIG Tracking AEFI during the campaigns Guiding SIG plan for reactivating EPI program

SAMS Third party in funding the training activities and guidelines printing in the 1st half of 2016

SEMA FLOs and health workers training on WBDs in Idleb

PAC Train the District Nutrition Officers in Aleppo and Idleb Train the vaccination team about vaccine cold chain management

UOSSM Third party in funding the vaccination campaigns

IDA and Shafak Third parties in the delivery process of Idleb and A’zaz laboratories

Gazi _ Lab PCR and blood culture techniques training for Lab staff

Idleb Health directorate Provide a secured place for the laboratory in Idleb city

Local authorities in : Al-Ha-sakeh, Jarablus , Menbij . Reactivation of EWARN and facilitating the related activities

Coordination to support partners Area of coordination

UNICEF Evaluation of drinking water sources in 10 governorates

SEMA Biological examination of drinking water sources in Idleb and Hama

IMC Evaluating the needs of epidemiological laboratory in Harim

UOSSM Performing sero-survey for HBV for 250 health worker in Bab Alhawa Hospital – Idleb.

Ihsan Evaluation the water quality in Idleb and Hama

Idleb Health directorate Support their statistics for communicable disease

Local authorities in besieged and hard to reach areas

Implementation for many vaccination campaigns (Polio R12 –MR- AIRI1 - AIRI 2 and AIRI3 )

NGOs health workers in SyriaTraining 739 health workers of the NGOs in Syria within 2016 on the prin-ciples of EWARN and the prioritized diseases (the details are in building capacity section).

Table 26 : Review of coordination details for EWARN team with different partners:



Figure 82: EWARN page statistics on ACU Website

At the end of 2015, and with more focus on both response and prevention, the importance of having a clear media plan was raised, in order to access to the largest recipients, spread the benefits to the target group, create an active and attractive channel with stakeholders, partners, beneficiaries and public.

- 4,203,673 people have seen the campaign`s advertisements on Google with 111,037 clicks per month during 2016.- The search results for EWARN on Google comes in the fourth position.

SECTION 7: OTHER DEPARTMENTS INVOLVEMENTAnnual Technical Report for Early Warning and Response Network

That could be briefed in the following items:

1- Website: continue to improve the EWARN page on the ACU website( http://www.acu-sy.org/en/early-warning-alert-and-response-network ) , and upload all the related materials (Reports – Guideline –Infographics – IEC materials). This has resulted in making EWARN page the most viewed on the web site by 9,163 out of 32,558 views per month.

2- Google Ad Words sponsored advertisements , through awareness campaigns about the dis-eases transmission and ways of preventions, and the visual reports for EWARN activities (training, vaccination campaigns, social mobilization … etc.). These resulted in the following statistics:

Figure 83: Google AdWords sponsored advertisements review

Figure 84: EWARN position on Google search

3- Social media: upload all the related activities and materials on social media.

Figures 85, 86, 87 : Examples for EWARN activities that published on Facebook.

7.1 Media aspect in EWARN

4- Interactive map :Designing an interactive map in coordination with IMU and DMT and set a time frame to finalize it.

https://goo.gl/byFwpt

Figures 88: EWARN coverage on the interactive map



Figures 89: Polio awareness animation film

5- Animation film:the production of the first cartoon film about poliomyelitis awareness as a first film of a series of animation films, followed by another film about Influenza, both aimed to increase the awareness about the communicable diseases, with a future plan to benefit the Syrians in particular and the Middle East in general.

Figures 90 : Influenza awareness animation film

Watch online Video https://goo.gl/VGE57v

Watch online Video https://goo.gl/JO8OY3

6- IEC materials:

Brochures EWARN definition Cholera awareness

Water treat-ment at home and safe storage

Typhoid fever awareness

Pertussis awareness

Influenza awareness for public

Posters Case definition

Influenza awareness for health workers

Rules of safe injection

Rules of preven-tion of water

contamination with sanitation

Hepatitis A awareness

Vaccination campaigns materials

Guide-lines AFP surveillance

Measles and Rubella surveillance

Laboratory Guidelines AEFI Surveillance

EWARN guidelines – English version

Others 2016 colanders and diaries

Annual report

Prevention of watercontamination with unclean ice – street banner

Aman hygiene campaign in

Rural Damascus –banners , cards,

posters

Prescription for clinician

Figures 91 to 99 : Examples of awareness brochures _ designed for EWARN

Table 27 : The main IEC material which have been designed in 2016 :



7- Videos (producing – photo – montaging):

Figures 105 : Payment methods in 2016

Videos Link Videos

Launch the campaign of ” Lets finish polio in Homs “ https://goo.gl/fiOSZW

Workshop of CLOs with WHO expert about outbreaks response in emergencies https://goo.gl/1NvtyV

Homs vaccine campaign R1 polio coverage ” Lets finish polio in Homs “

https://goo.gl/ZeD4zchttps://goo.gl/JM9EfX

AIRI 1 vaccination campaign in Homs https://goo.gl/OfLn0A

First quarterly meeting coverage https://goo.gl/RTyh9D

Second quarterly meeting coverage https://goo.gl/T6vOL3

Third quarterly meeting coverage https://goo.gl/mMCYzr

Figures 100 to 104 : Guidelines for AFP , Measles and Rubella , AEFI Surveillance and Laboratory – designed for EWARN

Financial stability played a key role in the success and in expanding the EWARN activities.Main Responsibilities of the finance officer in the EWARN team are:- Finding the most appropriate applicable way for documentation.- Keeping financial records and an electronic archive- Internal financial controls: ensuring that all expenditures are properly authorized and within budget lines.- Budgeting and following up budget lines.- Financial reporting

Most of the finance aspects have been stable as the fund is considered to be secured. The key challenge remains in the timing of cash flow as it is critical for program validity and credibility. Maintaining such levels was a bit of a challenge, especially at the start of 2016, as grant reporting and receiving timely approvals for the 2016 plan required time and procedures.Based on that we plan to process end of year expenses earlier with defined deadlines for our staff inside Syria to make sure there is more time available for grant reporting and the process for grant approval for the new year.Also more attention will be paid to the timing of cash out flows as it is concentrated in the last quarter of each year due to materials purchasing and the stocks replenishment process.

It was planned to expand the direct payment method where applicable as it gives more credibility to the program. The map below shows the payment method as in mid_2016 , the direct payment method for third level team (FLOs) means that they get the salaries directly from preselected cashpoints with no need to involve the second level team (DLOs) in the payment process for transparency issues.

7.2 Financial aspect in EWARN:

For more information contact Us:

e w a r n @ a c u - s y . o r gw w w . a c u - s y . o r g / e w a r n

Early Warning Alert and Response Network ANNUAL TECHNICAL ... · In 2016, more than 31 alerts of...

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