1. Evaluation of Brucellosis Surveillance System in the West Bank - Palestine, 2014 - June 2015 Huda Lahham, PharmD Palestinian Ministry of Health Funded by the European Union

2. Demographics of Palestine Funded by the European Union Population (4.7 million) West bank: 2.9 million Gaza strip: 1.8 million Area Km 2 West Bank : 5,671 Km 2 Gaza Strip : 360 Km 2 Rural, Urban, and camp Areas 73.8 % residing in urban areas 16.9 % residing in rural areas 9.3 % residing in refugee camps

3. Brucellosis Surveillance System- Palestine Geographic coverage : West Bank and Gaza Strip. Passive surveillance system. Weekly notified disease. 3 Funded by the European Union

4. Surveillance System Flow Chart 4 Public Sector Private Sector/NGOs Primary Health Care Centres/MOH Onset of Disease Central PH Laboratory/MoH Hospitals/MoH NGOs/Private Clinics/ Hospitals NGOs /Private Laboratories Central/ Preventive Medicine Dep. United Nations Relief & Works Agency Gaza Strip Funded by the European Union

5. Evaluation of Brucellosis Surveillance System- West Bank, 2014- June 2015 Objective: The first evaluation of brucellosis surveillance system to identify areas that need improvement. Evaluated attributes : Completeness Completeness of case reporting. Completeness of surveillance data Timeliness Representativeness Funded by the European Union

6. Methodology Both CDC and WHO guidelines were used. WHO case definition of brucellosis cases. Capture-recapture method. Data collection:  Participants: all hospitals, primary healthcare centers, all laboratories, and Central Preventive Medicine Department CPMD in the West Bank ( Governmental, private, and NGOs).  The variables used for pair identification: Full name Date of birth City of residency  Data was collected from 10 th June to 15 th of July/2015 Participation rate:  Governmental sector 100%  Private sector and NGOs 84% Funded by the European Union

7. Results Funded by the European Union

8. Completeness 1 - Completeness of case reporting (Sensitivity) Capture- recapture method Number of cases notified to PMD, cases diagnosed in NGOs & Private sector, and matching cases, 2014- June 2015 YearNo. of notifications to CPMD No. of cases in Private & NGOs No. of matched records Proportion of cases in Private & NGOs notified to CPMD 201436816511368% 201543626811944% 8 Funded by the European Union

9. Completeness 1- Completeness of case reporting (Sensitivity) YearTotal estimated number of cases in population, 95% CI Sensitivity of notification to CPMD, 95% CI Sensitivity of private and NGOS, 95% CI Incidence per 100,000, 95% CI 2014534 (489-579) 69% (65-73) % 31% (27-35) % 19.8 (18.1-21.5) 2015978 (870-1090) 45% (42-48) % 27% (24-30 )% 9 Using Chapman’s Formula Total number of estimated cases, sensitivity of notification to PMD and sensitivity of private sector and NGOs, and Incidence, 2014- June 2015 Funded by the European Union

10. Completeness 2- Completeness of surveillance data Funded by the European Union

11. Timeliness Funded by the European Union

12. Timeliness of reporting, 2014 Computation of timeliness reporting, “Non-zero” reporting system Information ItemCalendar QuarterYearly total Jan.-Mar.Apr.-JuneJuly-Sep.Oct.-Dec. Number of reporting sites to CPMD 16 The total number of reports received within time period (irrespective of the time of receipt) 62606362247 Total number of reports received on time within the time period 2420182385 Timeliness of reporting39%33%29%37% 34% 12 Funded by the European Union

13. Timeliness of reporting, 2015 Computation of timeliness reporting, “Non- zero reporting system Information ItemTotal Jan.-Mar.Apr.-June Number of reporting sites to PMD16 The total number of reports received within time period (irrespective of the time of receipt) 6669135 Total number of report received on time within the time period 131427 Timeliness of reporting20% 13 Funded by the European Union

14. Time points for Brucellosis Surveillance System Cumulative Time CT Disease Onset Notification/CPMD Registry Time RT Disease Onset Registration No tification Time NT Diagnosis Notification /CPMD 14 Funded by the European Union

15. Cumulative Time CT: time from disease onset to notification CT Disease Onset Notification/CPMD 35 days 15 Funded by the European Union

16. Registration Time RT: time from disease onset to registration RT Disease Onset Registration/Health center 8 days 16 Funded by the European Union

17. Notification Time NT: time from diagnosis to notification Diagnosis Notification/PMD 20 days 17 Funded by the European Union

18. 3- Representativeness  Age  Gender  Place of residency Funded by the European Union

19. 3- Representativeness Comparing notified cases and not notified cases to CPMD by gender and place of residency Notified to CPMD (n), % n= 803 Not notified to CPMD (n), % n= 202 p- value Gender Female 346 (43%)83 (41%)0.33 Male 457 (57%)119 (59%) Place of Residency North 41 (5%)16 (8%)0.29 Middle 79 (10%)18 (9%) South 683 (85%)168 (83%) 19 Funded by the European Union

20. 3-Representativeness Comparing notified cases and not notified cases to CPMD by age Notified to CPMD (n), % n= 803 Not notified to CPMD (n), % n=202 p- value Age group 0.53 <10 65 (8 % )11 (6%) 10-24 313 (39%)79 (39%) 25-39 200 (25%)49(24%) 40-54 157(20%)37(18%) 55-69 54 (7%)18 (9%) >= 70 14 (2%)8 (4%) 20 Funded by the European Union

21. Conclusions The notifications of labs in private sector & NGOs to PMD is decreasing in 2015 compared with 2014, which accordingly affect the sensitivity of surveillance system. Primary healthcare centers/ MoH showed remarkable delay in reporting after diagnosis. Furthermore, Patients present to their practitioners showed another delay. Not having a 100% of key information of patient (address & phone, Occupation) will affect conducting effective infection control. Our surveillance system showed representativeness in term of gender, age, and place of residency by comparing the notified cases to PMD and missed cases which detected by this study. Funded by the European Union

22. Recommendations Increase awareness among physicians /MoH about the importance of notifying diseases in a timely manner and the importance of having complete filled out notification form. Study the possibility of introducing electronic reporting system and networking. Promote public education about brucellosis and the importance of receiving an early management. Mandatory reporting from private and NGOs laboratories of brucellosis cases. Re-visit our surveillance objectives and plans for eradicating brucellosis. Periodic evaluation of brucellosis surveillance system. Funded by the European Union

23. Thanks Funded by the European Union