Analysis of the Information Management System for Acute Flaccid Paralysis Surveillance in Togo

Analysis of the Information Management System for Acute Flaccid Paralysis Surveillance in Togo

Wankpaouyare Gmakouba¹, Kossi Tarkpessi², Ditorgue Kodjo Assonde³

¹Ministry of Health and Public Hygiene, Lomé, Togo, Public Health Specialist, PhD Candidate, Bircham International University

²Public Health Specialist, Ministry of Health and Public Hygiene, Lomé, Togo

³Ministry of Health and Public Hygiene, Senior Laboratory Technician

^*Correspondence Author

DOI: https://dx.doi.org/10.47772/IJRISS.2024.8120359

Received: 18 December 2024; Accepted: 23 December 2024; Published: 24 January 2025

ABSTRACT

The Global Polio Eradication Initiative remains relevant only if acute flaccid paralysis (AFP) surveillance systems maintain optimal performance. Regular evaluations of these systems are essential to identify shortcomings, enhance capacity, and ensure an appropriate response. In this context, a comprehensive analysis of the documentation and communication methods used during AFP case investigations was conducted in the Ogou health zone in Togo. This assessment aimed to highlight potential gaps and propose corrective measures to strengthen the fight against polio.

Methods:

A cross-sectional study was carried out across 13 primary healthcare centers, the district health laboratory, and the national reference laboratory, which are critical links in the AFP epidemiological surveillance chain. Data were collected using a structured grid to extract information from registers, suspect case investigation forms, AFP notification forms, stool sample accompanying forms, and weekly reports. Additionally, semi-structured individual questionnaires were administered to personnel involved in AFP case investigations to gather their perspectives and experiences.

Results:

The AFP surveillance system’s responsiveness was generally satisfactory, with a median alert notification time of 18 hours, below the prescribed threshold of 24 hours. Report completeness was also deemed satisfactory. However, timeliness in transmitting results, both by the national reference laboratory and the primary healthcare centers, remained insufficient. Evaluating the information management system revealed logistical and organizational deficiencies within the AFP surveillance system.

Keywords: Surveillance, Information, Poliomyelitis, Togo

INTRODUCTION

Effective surveillance of any health event requires several essential activities: detection (identification of cases and outbreaks), recording, confirmation (both epidemiological and laboratory-based), reporting (early or systematic notification), as well as analysis and interpretation【1】. In 1998, during the 48th session of the WHO Regional Committee in Harare, Zimbabwe, a strategy for acute flaccid paralysis (AFP) surveillance was adopted【2】. The Global Polio Eradication Initiative remains relevant only if surveillance systems are regularly evaluated【3】. Effective surveillance relies particularly on robust documentation and communication systems【4】.

In the  of Togo, the documentation and communication system for AFP case investigations is structured as follows (Figure 1):

Community Level: This includes community relays, opinion leaders (religious, traditional, and political), traditional health practitioners, and other resource persons. Their role is to alert the nearest health center in the event of any suspected AFP case, defined as “any child under the age of 15 presenting with acute flaccid paralysis of sudden onset”【5】.

Primary Care Facilities: These facilities are responsible for completing the investigation form, collecting stool samples, and ensuring their transportation in coolers to the health zone laboratory. They also submit a weekly report to the district laboratory, no later than the Tuesday following the reporting week.

District Health Laboratory: The laboratory receives and stores samples before forwarding them to the national laboratory. It also submits a weekly report to the national laboratory within the same timeframe.

National Reference Laboratory: The national laboratory confirms cases and transmits the results back to the district laboratory. These results are then communicated to the source of the alert (community level) through the district laboratory and the relevant primary care facilities.

This study evaluated the documentation and communication system used for AFP case investigations in the Ogou health zone, aiming to identify existing shortcomings and propose recommendations for their correction.

METHODOLOGY

This cross-sectional study was conducted over six months, from January 1 to June 30, 2024. It covers the AFP surveillance period extending from week 1 to week 26 of the year.

Study Sites

The AFP surveillance system in the Ogou health zone relies on the collaboration of six first-tier health centers and the district health laboratory.

Data Collection Techniques and Tools

Data were collected through the review of records and interviews with stakeholders involved in AFP surveillance, using a validated collection grid and a semi-structured questionnaire that had been pre-tested. The grid contained six key categories: detection, recording, sample management, confirmation, data reporting, and transmission. The questionnaire included 16 questions divided into three categories: task distribution, information management tools, and system administration. This approach allowed for an in-depth evaluation of the surveillance system’s functioning.

Data Sources

Stakeholders involved in AFP case investigations and surveillance documents, such as registers, suspect case investigation forms, AFP notification forms, stool sample accompanying forms, and weekly reports, constituted the primary data sources.

Sampling

Six (6) health centers in the Ogou health zone involved in AFP surveillance between January 1 and June 30, 2024, were selected. All personnel present during the study who consented to participate were interviewed. Additionally, all available documents containing AFP investigation data were reviewed.

These criteria include the accessibility of health facilities (USPs) to ensure effective monitoring, the volume of previous reports to guarantee relevant data, the quality of reports for comprehensive documentation, and the speed of notification for optimal responsiveness. The presence of trained personnel and the availability of adequate materials, such as notification forms and sample collection tubes, are also essential elements considered. Furthermore, stakeholder consent is crucial to ensure active collaboration, while the history of epidemics in these USPs provides a basis for evaluating their performance in critical contexts. Together, these factors strengthen the system’s ability to detect, report, and respond effectively to AFP cases.

Definition of Indicators

Four indicators were selected to assess the AFP surveillance documentation system【6】:

Responsiveness: Measured by two aspects: the time required to document alerts (notification in the questionnaire) and the interval between stool sample collection and the receipt of confirmation results by the concerned primary health center.

Timeliness: Defined by the proportion of information reporting tools (weekly reports and result bulletins) submitted within planned deadlines out of the total tools submitted.

Completeness: Represented by the proportion of submitted information reporting tools (weekly reports and result bulletins) compared to the total tools expected during the period.

Acceptability: Assessed based on the individual perceptions of stakeholders involved in the surveillance, focusing on two criteria: i) the applicability of field procedures (definition of suspected AFP cases, stool collection, sample transport, weekly report submission, and results transmission), ii) the functionality of various components of the surveillance chain.

RESULTS

Status of AFP Surveillance During the Study Period

In total, five suspected case alerts were recorded by the six primary health centers, resulting in stool sample collection for each alert. No cases were confirmed during the study period. Detection activities involved 28 individuals, distributed as follows: 9 at the community level, 12 primary health workers, 4 district laboratory technicians, and 3 technicians at the central reference laboratory. Of these 28 individuals, 23 were located and interviewed, including 8/9 at the community level, 10/12 primary health workers, 3/4 district laboratory technicians, and 2/3 central reference laboratory technicians.

System Responsiveness

The median time for notification of the five alerts, as reported in the questionnaire, was 12 hours, with a range from 30 minutes to 24 hours. The median time between stool sample collection and receipt of confirmation results by the concerned primary health center was 14 days, with minimum and maximum durations of 10 and 35 days, respectively.

Timeliness

Among the six primary health centers, 98% of weekly reports were submitted on time (Table I). The district health laboratory met the deadlines for 96% of its reports. The national reference laboratory transmitted 60% of its results to the district laboratory within the stipulated 14-day period. The district laboratory, in turn, sent all received results to the concerned primary health centers within 24 hours of receipt.

 Table I : Timeliness

Completeness

During the study period, the six primary health centers submitted 98% (153/156) of the expected weekly reports to the district health laboratory. The district laboratory, in turn, submitted 100% (150/156) of its reports to the national laboratory. The national laboratory sent 60% (3/5) of the expected results to the district laboratory, which subsequently forwarded 100% (3/3) of the received results to the concerned primary health centers.

System Acceptability Among Stakeholders

The implementation of established procedures was inconsistent among stakeholders. Specifically, 78% (18/23) of respondents reported adhering to stool sample collection procedures, while only 26% (6/23) correctly applied the standard AFP case definition (Table II).

The functionality of the surveillance chain was hindered by logistical issues (e.g., shortages of notification forms and collection tubes, recurring failures in the cold chain for sample storage) and organizational challenges (e.g., irregular supervision of sample collection personnel and lack of reliable addressing systems to locate community relays and/or suspected cases).

Perceptions of Procedure and Standard Implementation in Surveillance

Stakeholders identified challenges in implementing certain surveillance procedures, which hinder the adoption of standards and the overall effectiveness of the surveillance system in the district.

Table II: Perceptions Regarding the Application of Surveillance Procedures and Standards

Improving System Acceptability

The challenges encountered in documentation and information transmission fall into two main categories: those related to resources and those related to processes.

Resource-Related Challenges:

• Frequent stockouts of notification forms and sample collection tubes hinder the proper functioning of the surveillance system.
• The absence of a stock management tool for reagents at the district laboratory complicates procurement planning.

Process-Related Challenges:

• The AFP investigation questionnaire is considered too lengthy, and difficulties arise in collecting certain data, such as the addresses of suspected cases and clinical signs.
• The lack of a systematic georeferencing system for suspected cases complicates their follow-up and the transmission of laboratory results.

Functionality of the Surveillance Chain

The absence of regular feedback between the reference laboratory and peripheral structures risks weakening the AFP surveillance system【14,15】. Without consistent communication, the relevance of alerts and the sense of engagement among community stakeholders may be undermined. A systematic georeferencing of suspected case addresses would facilitate follow-up and medical management.

Additionally, frequent cold chain failures, critical for sample preservation at district laboratories, pose a significant challenge. Developing and implementing a proper maintenance plan could ensure the sustainability of this essential logistics component.

DISCUSSION

Study Limitations

The potential bias in site selection, the relatively small sample size and the qualitative approach used limit the generalisability of the results to all health districts in Togo. However, the results provide valuable indications for improving the surveillance system in the Ogou health zone and in similar contexts.

Health Data Management is designed to collect, store, process, and analyze health-related information, but surveillance systems, while providing valuable insights, face several limitations and weaknesses. These include data quality issues such as incomplete data, inaccuracies, and standardization challenges; limited access and interoperability between systems; privacy concerns and ethical challenges; bias in data representation; cost and resource constraints; overreliance on structured data that limits complex analyses; ethical risks associated with surveillance activities; and limited generalizability of results. Addressing these challenges requires improving data governance, strengthening system interoperability, ensuring real-time data availability, and enhancing data quality.

Relatively Satisfactory Responsiveness

The rapid transmission of collected information is fundamental to the effectiveness of any epidemiological surveillance system. The median alert notification time of 18 hours falls within the planned threshold of 24 hours. However, these delays are influenced by geographical distances and obstacles between first-tier health centers and suspected cases. Previous studies have attributed low responsiveness to deficiencies in communication and transportation systems between health districts and first-contact facilities【7,8】. In the Ogou health zone, responsiveness is relatively high due to the provision of transport (motorcycles) and the establishment of a free telephone communication network among first-tier health facilities and the district.

Satisfactory Completeness but Timeliness Needs Improvement

Report completeness is satisfactory, supported by regular training and updates in the national health information system. However, timeliness in result transmission remains insufficient: only 60% of results from the national laboratory and all results from first-tier health centers were transmitted within the required timeframes. This delay is attributed to inadequate deadline management at the national laboratory and the limited availability of health personnel. The high workload of these workers is frequently cited as a significant cause of delay, mirroring challenges observed in Benin and Burkina Faso【9,10】.

Addressing Challenges to Improve Acceptability

To improve the acceptability of the surveillance system among stakeholders, it is essential to address identified challenges, which can be categorized into resource-related and process-related issues.

Resource-Related Issues:

• Frequent stockouts of essential materials, such as notification forms and sample collection tubes, hinder system functionality.
• Delays in the supply chain and poor resource management at usage points are frequently reported【11,12】.

Process-Related Issues:

• The investigation questionnaire is considered overly detailed, posing challenges in filling out sections such as patient addresses and clinical descriptions.
• The absence of systematic georeferencing complicates case tracking and laboratory feedback.

Lack of regular feedback from the reference laboratory to peripheral structures risks undermining the AFP surveillance system【14,15】. Without such feedback, the relevance of alerts and community-level engagement may be questioned. Systematic georeferencing would facilitate follow-up and improve communication between actors.

Cold Chain and Logistical Challenges

Frequent breakdowns in the cold chain for sample storage represent a significant challenge. Implementing a maintenance plan for cold storage systems would help ensure the sustainability of critical logistics.

Recommendations for Strengthening AFP Surveillance in

To strengthen AFP surveillance in the , it is essential to improve resource management through stock tracking tools and adequate logistical support, while providing regular training and mentoring for health staff and community relays. Simplifying reporting tools and integrating mobile technologies (mHealth) would facilitate data collection and transmission, while awareness-raising campaigns and feedback mechanisms would strengthen stakeholder commitment. At the same time, the introduction of maintenance plans for the cold chain and geolocation tools would improve the infrastructure, and the integration of these efforts into national health strategies would ensure their sustainability. Finally, advocacy for increased funding from local and international partners is needed to support these initiatives in the long term.

CONCLUSION

Although polio is now a rare disease, its surveillance remains critical as the possibility of resurgence persists. This study identified several shortcomings in the AFP surveillance system, particularly in the timeliness of feedback, resource management, and the use of information collection tools. To improve the system, the following measures are recommended:

Implement stock management tools for perishable resources and establish alert stock levels to prevent frequent stockouts.

Simplify information collection tools to reduce the burden on health workers.

Improve addressing systems for suspected cases to facilitate tracking and follow-up.

Ensure regular and systematic feedback from the national reference laboratory to peripheral facilities to maintain the functionality and engagement of all actors.

By addressing these challenges, the AFP surveillance system in the  can be strengthened, contributing to the ongoing fight against polio and supporting broader public health surveillance efforts.

REFERENCES

1. World Health Organization. (2001). Protocol for the assessment of national communicable disease surveillance and response systems: Guideline for assessment teams (130 p.). Genève: WHO. En ligne : http://apps.who.int/iris/handle/10665/66787
2. Perry, H. N., McDonnell, S. M., Alemu, W., Nsubuga, P., Chungong, S., Otten, M. W. Jr., et al. (2007). Planning an integrated disease surveillance and response system: A matrix of skills and activities. BMC Medicine, 5(24), 8 p. https://doi.org/10.1186/1741-7015-5-24
3. Desai, S., Smith, T., Thorley, B. R., Grenier, D., Dickson, N., Altpeter, E., et al. (2015). Performance of acute flaccid paralysis surveillance compared with World Health Organization standards. Journal of Paediatrics and Child Health, 51(2), 209-214. https://doi.org/10.1111/jpc.12691
4. Sorbe, A., Chazel, M., Gay, E., Haenni, M., Madec, J. Y., & Hendrikx, P. (2011). A simplified method of performance indicators development for epidemiological surveillance networks – Application to the RESAPATH surveillance network. Revue d’Épidémiologie et de Santé Publique, 59(3), 149-158.
5. Ministère de la santé. (2012). Guide technique pour la surveillance intégrée de la maladie et la riposte au Burkina Faso (210 p.). Ouagadougou : Ministère de la santé.
6. World Health Organization. (2006). Communicable disease surveillance and response systems: Guide to monitoring and evaluating (81 p.). Genève: WHO. (Epidemic and pandemic alert and response). En ligne : http://apps.who.int/iris/bitstream/10665/69331/1/WHO_CDS_EPR_LYO_2006_2_eng.pdf?ua=1
7. Mboera, L. E., Rumisha, S. F., Mwanemile, E. J., Mziwanda, E., & Mmbuji, P. K. (2005). Enhancing disease surveillance reporting using public transport in Dodoma district, Central Tanzania. Tanzania Health Research Bulletin, 7, 201-205.
8. Nsubuga, P., Eseko, N., Tadesse, W., Ndayimirije, N., Stella, C., & McNabb, S. (2002). Structure and performance of infectious disease surveillance and response. Bulletin of the World Health Organization, 80(3), 196-203.
9. Adeya, G., Bigirimana, A., Cavanaugh, K., & Miller Franco, L. (2006). Évaluation rapide du système de santé du Bénin (142 p.). Bethesda (MD)
10. Drabo, K. M., Nana, F., Kouassi, K. L., Konfé, S., Hien, H., Saizonou, J., & Ouedraogo, T. L. (2015). Poliomyelitis case surveillance data management in Burkina Faso. Sante Publique, 27(6), 855-861.
11. Abdou Ousseini, M. (2002). Étude du système d’information hospitalier à l’hôpital de zone de Ouidah, Département de l’Atlantique [Mémoire de maîtrise en Santé Publique]. Cotonou : IRSP/UAC.
12. Mutale, W., Chintu, N., Amoroso, C., Awoonor-Williams, K., Phillips, J., Baynes, C., et al. (2013). Improving health information systems for decision making across five sub-Saharan African countries: Implementation strategies from the African Health Initiative. BMC Health Services Research, 13(Suppl 2), S9. https://doi.org/10.1186/1472-6963-13-S2-S9
13. Berg, M. (1999). Patient care information systems and healthcare work: A sociotechnical approach. International Journal of Medical Informatics, 55(2), 87-101. https://doi.org/10.1016/S1386-5056(99)00011-8
14. Gebrehiwot, T., San Sebastian, M., Edin, K., & Goicolea, I. (2014). Perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia. BMC Pregnancy and Childbirth, 14, 137. https://doi.org/10.1186/1471-2393-14-137
15. Bakeera, S. K., Wamala, S. P., Galea, S., State, A., Peterson, S., Pariyo, G. W. (2009). Community perceptions and factors influencing utilization of health services in Uganda. International Journal for Equity in Health, 8, 25. https://doi.org/10.1186/1475-9276-8-25
16. Ledikwe, H. J., Grignon, J., Lebelonyane, R., Ludick, S., Matshediso, E., Sento, B. W., et al. (2014). Improving the quality of health information: A qualitative assessment of data management and reporting systems in Botswana. Health Research Policy and Systems, 12, 7. https://doi.org/10.1186/1478-4505-12-7