Partners and Frameworks for IDSR and IHR - The Stimson Center

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Partners and Frameworks for IDSR and IHR - The Stimson Center

Partners and Frameworks for IDSR and IHR (2005) Implementation

Dar es Salaam, Tanzania

December 11 -13, 2011

In December 2011, the WHO Regional Office for Africa, the Stimson Center, and the George

Washington University School of Public Health and Health Services co-hosted a workshop to

highlight the implementation of the revised International Health Regulations in the context

of the regional Integrated Disease Surveillance and Response strategy. This workshop took

place in conjunction with the 4th Scientific Conference hosted by the African Field

Epidemiology Network (AFENET) in Dar es Salaam, Tanzania.

Participants shared their perspectives on progress toward implementation of IDSR/IHR in

sub-Saharan Africa. The workshop helped frame the case for sustainable investment in

integrated disease surveillance and response from the community to the national levels.

Sessions focused on progress and tools for implementing IDSR and IHR, public health

workforce needs, national and partner perspectives, and lessons learned.

Introduction

In 1998, the Member States of the World Health Organization’s Regional Office for

Africa (WHO/AFRO) adopted the Integrated Disease Surveillance and Response (IDSR)

strategy to improve public health responses to diseases that are leading causes of

death, illness and disability in African communities. 1 In 2005, all WHO Member States

agreed to the revised International Health Regulations [IHR (2005)], a binding

commitment to strengthen the core capacities required to detect, assess, report, and

respond to public health events before they become international crises.

The IDSR and IHR (2005) frameworks mutually emphasize the development of core

capacities to detect, confirm, report, and respond effectively to priority diseases and

conditions at every level of national health systems.

National health authorities in the region have worked with WHO/AFRO and a number

of key partners (including the U.S. Centers for Disease Control and Prevention (CDC),

the U.S. Agency for International Development (USAID), and the African Field

Epidemiology Network, or AFENET) to develop and maintain the capabilities required

to implement these two interconnected strategies. The revision of the technical

guidance for IDSR implementation in 2010-2011 and the requirement for nations to

report their IHR (2005) implementation status to WHO in June 2012 create an

opportunity to identify lessons learned from ongoing efforts, and to engage new

actors in realizing the potential of the IDSR/IHR frameworks.


IDSR/IHR Workshop Report

The Integrated Disease Surveillance and Response Strategy

The IDSR strategy aims to “improve the ability of all levels of the health system to detect,

confirm, and respond to diseases and other public health events in order to reduce high levels

of death, illness and disability in African communities.” 2 To accomplish this, WHO/AFRO

member states committed to improving the availability and use of disease surveillance and

laboratory data, and to making more effective use of resources by integrating disease detection

and control programs – a solution to the programmatic “silos” often created by disease-focused

funding streams.

The IDSR technical guidelines, developed jointly by WHO/AFRO and CDC, help define

surveillance, response, and

laboratory core functions at each The IDSR strategy emphasizes three general goals:

level of a health system. The

guidance also includes sample tools,

case definitions, and indicators for a

comprehensive list of diseases and

conditions of regional and global

public health significance. 3



Strengthening public health surveillance and

response capabilities for priority infectious

diseases, focusing on the district level;

Enhancing laboratory capacities to support

disease detection and epidemic confirmation;

and

Forty-four of the 46 WHO/AFRO

Member States began phased

implementation of the IDSR strategy


Translating surveillance and laboratory data into

specific and timely public health actions.

around the year 2000, starting by adapting the technical guidance to reflect national disease

detection and control priorities. Officials developed national IDSR implementation plans, began

sensitizing stakeholders, and adapted and launched modules to train health workers to collect

and report surveillance data on a weekly basis. 4

Adoption of the IHR (2005)

The IHR (2005) are a binding agreement among 194 nations regarding surveillance for and

response to public health emergencies. Under the revised regulations, the WHO Director-

General may declare any natural, accidental, or deliberate event a “public health emergency of

international concern,” or PHEIC, if it has the potential to affect health across national borders.

The revised IHR (2005) shifted the emphasis of international cooperation from controlling a few

diseases at ports and borders to containing public health threats when and where they occur.

The IHR (2005) conferred new obligations on countries to prepare for outbreaks and other

disasters, and new responsibilities and authorities on WHO to collect and share information

necessary for a coordinated international public health response. The success of this more

flexible approach depends not just on timely and transparent reporting of public health events,

but on adequate national and sub-national capacities for disease detection, assessment,

reporting, and effective response. The IHR (2005) do not just create a framework for disease

reporting – they help define what constitutes adequate local disease detection and response

capacities in the spirit of reciprocal responsibility among nations.

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IDSR/IHR Workshop Report

Operationalizing IHR in the Context of IDSR

In 2006, WHO/AFRO – following a series of regional consultations – affirmed that “application

of the IHRs (2005) in the African Region will proceed in the context of the Integrated Disease

Surveillance and Response (IDSR) strategy that the WHO Regional Committee for Africa

adopted in 1998.” 5 IDSR would serve as a platform for building IHR core capacities (particularly

Surveillance and Response), while IHR obligations would reinvigorate IDSR implementation.

To reflect this, WHO/AFRO, with support from CDC, updated the IDSR guidance to incorporate

the indicators and reporting mechanisms required under IHR (2005), as well as other new

regional health priorities. The 2010 revision of the IDSR Technical Guidelines redefined the

IDSR priority diseases, events, and conditions to encompass an expanded list of epidemic-prone

diseases, diseases targeted for eradication or elimination, diseases or events of international

concern, and other major diseases, conditions, or events of public health importance.

WHO/AFRO released updated generic training modules in 2011. The new guidance, which

includes comprehensive case definitions, provides nations with templates for aligning their IDSR

and IHR implementation strategies operationally. 6

Source: World Health Organization Regional Office for Africa and US Centers for Disease Control and Prevention,

Technical Guidelines for Integrated Disease Surveillance Response in the African Region. October 2010.

IDSR/IHR – A Process, Not an Outcome

Both IDSR and IHR (2005) represent frameworks for building, strengthening, and maintaining

capacities over the long term. Participants in the December 2011 workshop described progress

toward implementation of these integrated strategies, and highlighted experiences – from

designing and conducting national assessments to engaging community leaders to cross-border

cooperation – that could inform sustainable practices for public health systems strengthening

across and beyond sub-Saharan Africa.

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IDSR/IHR Workshop Report

Throughout the process of IDSR (and now IDSR/IHR) implementation, WHO/AFRO has provided

ongoing technical assistance with support from CDC and other partners (including USAID, other

UN agencies, and private institutions such as the Gates and Rockefeller Foundations).

Workshop participants also identified opportunities to strengthen ongoing partnerships and

build new ones using the IDSR/IHR frameworks as a guiding principle.

Figure 1: Countries in WHO/AFRO implementing IDSR (2010), December, 2012

IDSR adopted

Source: Adapted from presentation Implementation of IDSR-IHR (2005) in the African Region by Peter Gaturuku at

the Partners and Frameworks for IDSR and IHR (2005) Implementation Workshop, 11 Dec 2011.

Assessment: One of the primary challenges in partnerships for public health capacity-building

lies in the need for stakeholders to document short-term measurable outcomes while

acknowledging that their investments will be realized on the scale of years, or even decades. In

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IDSR/IHR Workshop Report

the last two years, national authorities in the region have assessed their progress toward

implementation of both IDSR and the broader obligations of IHR (2005).

In 2010, WHO/AFRO disseminated a rapid self-assessment tool to help national authorities

evaluate IDSR implementation. Forty-three of the 45 countries that responded reported some

progress, demonstrated most tangibly by those that publish weekly reports on priority disease

cases and on the timeliness and completeness of reporting at the district level.

This assessment also helped inform the process of reviewing IHR-relevant core capacities. In

2009, Kenya piloted an intensive IHR core capacity assessment with WHO/AFRO technical

support, requiring multiple trained teams at the central, intermediate, and peripheral levels.

Based on this experience, WHO/AFRO worked with Member States and technical partners to

develop an enhanced desk review tool for IHR (2005) core capacities. As of November 2011, an

estimated 37 countries in the region had completed the core capacity assessment required

under IHR (2005) to identify gaps in current capabilities and inform their IHR national action

plans. By June 2012, all IHR (2005) States Parties will be required to report to WHO whether

they have achieved the core capacities necessary to implement the IHR (2005) fully, or will

require a two-year extension.

Challenges: These assessments not only help national leaders identify specific gaps, but can

highlight trends or systemic challenges shared across borders. For example, most countries

have developed a national public health surveillance structure and process, but only 24

countries reported having an emergency operations center in place as suggested by the IHR

Monitoring Framework. 7 IDSR assessments consistently pointed to gaps in district-level

implementation. Of the 43 countries currently implementing IDSR, only 35 reported

implementing the strategy in all of their districts. The challenge of scaling up successful

programs will be compounded as countries incorporate the expanded list of priority diseases,

conditions, and events introduced in 2010. Shortages of skilled public health workers and of

time, resources, and expertise to plan emergency responses, make effective local use of

surveillance data, and monitor and evaluate IDSR indicators are among the limitations.

Benefits: Despite gaps in full implementation of IDSR/IHR at the district level and below in many

countries, standardized reporting is paying off in the increased availability of timely, reliable

data on priority diseases and conditions. Such information allows WHO/AFRO and other

partners to evaluate communicable and non-communicable health threats at the regional level

to identify risk factors and opportunities for coordination across sectors and borders, and to

develop appropriate technical guidance and tools for use at the national level.

The availability of accurate data on the distribution and impact of priority diseases also provides

national health officials with leverage to engage stakeholders beyond the health sector. As an

example, the capacities for disease detection built under the IDSR/IHR strategies helped

pinpoint the risk factors and systemic weaknesses that perpetuated severe periodic cholera

outbreaks in Kenya between 2006 and 2010. This information helped Kenyan health officials

convene stakeholders across ministries and sectors to develop a coordinated plan of action

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IDSR/IHR Workshop Report

aimed at detecting, managing, and ultimately preventing cholera outbreaks, with specific

budgets and shared core indicators for measuring progress. As shown in Figure 2, many

countries in the region have adopted policies and budgets to facilitate IDSR implementation.

Figure 2: WHO/AFRO Countries with Policies and/or Budgets for IDSR

45

IDSR Rapid Assessment Reports - 2010

Policy and Budget for IDSR

Number of Coutntries

40

35

30

25

20

15

30

33

22

33

10

5

0

Have regulations or

legislation governing

health suveillance

Have a national policy

for IDSR

implementation

Have a national budget

line for IDSR

Receive funds from

donors or NGOs

Source: Graph created from data in presentation by Dr. Peter Gaturuku, Implementation of

IDSR-IHR (2005) in the African Region, at the Partners and Frameworks for IDSR and IHR (2005)

Implementation Workshop, 11 Dec 2011.

Systems Approaches to Public Health Surveillance and Response Practices

The IDSR/IHR frameworks establish goals for developing comprehensive public health

surveillance capacities rather than targeting a single disease or condition. This is a new

development, even for organizations that have engaged in capacity-building for decades.

Strengthening public health surveillance and response systems from the central to the

community level requires a skilled health workforce, infrastructure, tools, equipment and

supplies, and cross-sector communications and coordination. For many epidemic-prone and

most emerging infections, outcomes must be measured indirectly as well as through

performance outputs.

Although concerns about epidemic-prone diseases underlay adoption of the IDSR/IHR

framework, the core capacities built to support timely detection and reporting of emerging

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IDSR/IHR Workshop Report

events can strengthen health systems across the board. Valid and accurate information allows

decision makers to assess population health status, identify the magnitude and scope of public

health risks, set priorities, evaluate interventions, track long-term trends, and shape the

research agenda – in short, to take all of the steps necessary to plan and implement evidencebased

health actions, as well as to control the spread of disease across borders. 8

Next Steps

The adoption of new IDSR technical guidance, and the looming requirement of all States Parties

to report their status on IHR (2005) implementation to WHO by June 2012, has catalyzed new

momentum for comprehensive public health systems strengthening in sub-Saharan Africa.

Few countries have openly shared information on lessons learned in building capacities for

IDSR/IHR implementation and from exercises and events. Although national health authorities

must chart their own courses to IDSR/IHR implementation based on local needs and

capabilities, the networks that are being built to share information on disease outbreaks and

other public health crises could also be used to share information on best practices in capacitybuilding

– a critical step to helping make the most effective use of limited resources. Workshop

participants identified various templates for cooperative capacity-building and coordination

across sectors and borders that deserve closer examination.

Building the necessary capacities will also require sustained commitment from national leaders

inside and beyond the health sector, as well as consistent funding over the long-term.

Resources to assist low and middle-income nations have not been forthcoming to the required

extent, in part because the demands and costs of public health systems strengthening to

support IDSR/IHR implementation remain poorly understood beyond the region.

The IDSR/IHR frameworks offer opportunities to engage partners at all levels, from

strengthening participation by community leaders to enhancing regional coordination for public

health emergencies. U.S. government partners described ongoing and new commitments to

helping countries in the region implement IDSR/IHR strategies, but specific needs and questions

remain.

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IDSR/IHR Workshop Report

Thoughts and Themes

*The information in the figure below stems from insights provided by workshop participants.

Human Resources

Inadequate workforce, especially at local levels

• What is required to make a strong Public Health Workforce? There is no model that includes

the competencies required.

• Staff turnover remains a problem, making maintaining a strong institutional memory

difficult.

• Health sector is often asked to respond to new and emerging health needs with little

assessment of the necessary human resources.

• A number of public health functions end up being performed by a variety of practitioners.

Financial Resources

Insufficent resources to support capacity building

• Countries are going to need real tools to implement IHR, many have actionable plans now,

but need partners.

Information and

Material Resources

Inadequate communication sharing / lack of materials

• Countries need to share information to identify best practices. Countries are feeling their

way toward more effective actions and better coordination with their neighbors. They are

getting better at sharing information during outbreaks, but even in tight-knit regions, there

are not enough forums for sharing information on capacity building.

• Consistency in availability and management of supplies and materials for disease detection --

from sample collection to diagnostic testing -- remains a problem, particularly at lower levels

and in laboratory settings.

Preparedness and

Response

Support and expertise for planning and learning from responses

• Need support for joint planning as well as joint field investigations and response.

• Need support to adapt locally relevant training materials.

• Preparedness and response plans that have been developed need to be tested.

• Post-outbreak reviews need to be conducted routinely to identify and share lessons learned.

• Support is needed to implement the IDSR training modules and to train for outbreak

preparedness and response, especially at the district and sub-district levels.

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IDSR/IHR Workshop Report

APPENDIX 1 – Workshop Agenda

Partners and Frameworks for IDSR and IHR (2005) Implementation

December 11 -13, 2011

Chairpersons: Dr. Helen Perry, US Centers for Disease Control and Prevention

Dr. Julie Fischer, Stimson Center

AGENDA

Day 1

9:30 A.M. – 10:00 A.M. Welcome and Registration/Tea Break

10:00 A.M. – 11:00 A.M. Introduction

• Nathan Bakyaita - WHO/AFRO

• Julie Fischer -Stimson Center

11:00 A.M. –12:00 P.M. Public health workforce models and needs for IHR

implementation

• David Mukanga (AFENET)

• Questions and Discussion

12:00 P.M. – 1:00 P.M. Implementing IHR (2005): USG perspectives on partnering

opportunities

USG capacity-building activities in the region

• Henry Walke – US Centers for Disease Control and

Prevention

• Erin Sorrell – US Department of State

• Aaron Boyd – US Department of Defense

1:00 P.M – 2:00 P.M Lunch

2:00 P.M. – 3:00 P.M. AFENET Opening Keynote

3:30 P.M. – 5:30 P.M. WHO/AFRO and Partners IDSR and IHR (2005) Update

• Implementation of IDSR and IHR (2005) in the WHO

African Region – Peter Gaturuku

• Overview of preparedness and response to outbreaks in

the WHO African region – Zabulon Yoti

• Development of a comprehensive multi-sectoral cholera

prevention and control plan in Kenya- David Mutonga

5:30 P.M. – 6:30 P.M. Discussion and Closing Remarks

• Led by Helen Perry and Julie Fischer

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IDSR/IHR Workshop Report

Day 2

Individual meetings to be arranged based on interest and conference schedule

Day 3

5:00 P.M. – 5:30 P.M. Building the Case for Investment in IDSR and IHR (2005)

Implementation:

Overview of Tools and Resources

• Julie Fischer, Stimson Center

5:30 P.M. – 6:30 P.M Breakout Sessions

1. IDSR implementation: national perspectives on best practices and

lessons learned in the African Region

• Moderators: Peter Gaturuku (WHO/AFRO) and Rudi

Thetard (Management Sciences for Health)

2. Implementing IHR in the context of IDSR - what policies, tools, and

resources are needed to bridge gaps between the old and new

technical guidelines?

• Moderator: Charles Njuguna (WHO Kenya)

3. Coordination and measuring outcomes in capacity building

• Moderators: David Mukanga (AFENET) and Prof. Mufuta

Tshimanga (University of Zimbabwe)

6:30 P.M. – 7:15 P.M. Reports of breakout sessions

7:15 P.M – 8:00 P.M Discussion and Closing Remarks

• Helen Perry

• Julie Fischer

• Nathan Bakyaita

Light Refreshments will be served throughout the evening session

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IDSR/IHR Workshop Report

APPENDIX 2 – List of Workshop Participants

Name

Organization

A. Nasidi NCDC/FMOH/Nigeria

Ahmed M. Fidhow

FELTP - Kenya

Alemayehu Bekele

EPHA - EFELTP - Ethiopia

Alex Charleston

CDC - Atlanta

Alfred de Silva

AMP France

Amwayi S. Anyangu

MOHPS - FELTP

Arthur Quaru

AFENET - Ghana

Augusto Lopez

CDC Atlanta

Barbara Green - Ajufu

CDC - Malawi

Brian Abg Mapoarua

FETP - Zimbabwe

Busuulwa Monday

AFENET

Celeste Harris

US - DoD

Celestin Hakiruwizera

ASM

Cesar Palho de Sousa (Palla Souse)

FELTP - Mozambique

Charles Njuguna

WHO Kenya

Chris Lewis

US - DoD

Clemeubhe (Clementine) Muroua

MOHSS - Namibia

Corine Karema

MOH_Rwanda

David Mukanga

AFENET

Dennis Lenaway

US - CDC

Diafuka Saila-Ngita

USAID RESPOND

Dickens Onyaugo

FELTP - Kenya

Douglas Hatch

USAID RESPOND - EPT

Dr. David Mutonga

MOHPS - Kenya

Dr. Evans Kiprotich

FELTP - Kenya

Dr. Adebobola Bashorun

NFELTP - NIGERIA

Dr. Ammar Abdo Ahmed

MOH - Djibouti

Dr. Balogum Muhammad

FELTP - Nigeria

Dr. Bitek Orinde

FELTP - Kenya

Dr. Daddi Jima

EHNRI - Ethiopia

Dr. David Mugabi

AFENET; Makerere University Vet School

Dr. Erin Sorrell

Dr. John Oladejo

Dr. Markin Mengel

Dr. Odong Calvin

Dr. Samuel Sackey

Dr. Stefanie Bumpus

Dr. Stella Kiambi

US - DoS

FMSH - NFELTP

AMP France

AFENET - Uganda

FELTP - Ghana

US - DoD

FELTP - Kenya

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IDSR/IHR Workshop Report

Dr. Wences Arvelo

Dr. Yatta L. Lugov

Eric Gogstad

Everline Muhonja

Gefnet Mikice

Geofrey J. Meham

Godbless Lucas

Grace Saguti

Helen N Perry

Henry Walke

Iatw Paul A

J Nghipundjwa

James Bangura

Jared Omolo

Jenny Tegelvik

John Ngulefac

Kamvane Samuel

Kashef Ijaz

Kathryn Harris

Lucia Takindua

Luez N

Lynee Galley

Mahmood M Dalhat

Major Aaron Boyd

Marie Aimme Muhimpundi

Mark Obury

Mary Muchekeza

Mayigane Landry

McKenzie Andre

Mike Majewski

Mohamed Karama

Monje Fred

Mulondo Henry

Mura Ngoi

Nathan Bakyaita

Nelson Muriu

Ntegzyibizaza Samson

Okey Nwanyanum

Olufemi Ajumolie

Ope Maurice

CDC - Kenya

Minister, MOH-RSS- Juba

CDC

FELTP Kenya

EFELTP - Ethiopia

MOHSW

TFELTP

WHO Country Office Tanzania

CDC - Atlanta

CDC

MOH - RSS - Juba

MOHSS - Namibia

FELTP - Sierra Leone

MOHPS - FELTP Kenya

WHO AFRO/RESPOND

CDC - FELTP

FELTP - Kenya

GDDER, CDC - Atlanta

US - DoD

FETP - Zimbabwe

MOH - Uganda

ASM

FELTP - Nigeria

US - DoD

FELTP - Rwanda

FELTP - Kenya

FETLTP - Zimbabwe

FELTP - Rwanda

CDC - Atlanta

US - DoD

KEMRI - Kenya

FELTP - Uganda

FELTP - Uganda

FELTP - Tanzania

WHO/AFRO

MOPHS - FELTP

FELTP - Rwanda

CDC - Nigeria

FELTP - Nigeria

East African Community

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IDSR/IHR Workshop Report

Pennelope Muyengua

Peter Edwards

Peter Gaturuku

Prof. Edwin Afari

Rafaule Nguku

Randrianarivo - Solofoisaina Armand

Eugene

Rudi Thetard

Ruth Cooke Gibbs

Ruton Hinda

Sabayefu Emmanuel

Thierry Nyatanyi

Victoria Fort

Viola Mushi

Zegeye Haifemariam

FETP - Zimbabwe

CDC - Atlanta

WHO - AFRO Brazzauiue

FELTP - Ghana

AFENET

FETP Madagascar (Indian Ocean Commission)

MSH/ASH

CDC

FELTP - Rwanda

FELTP - Rwanda

MOH - Rwanda

CDC - IDSR

TFELTP - Tanzania

EFELTP - Ethiopia

References

1 WHO Regional Committee for Africa: Integrated Diseases Surveillance in the African Region: A Regional Strategy

for Communicable Diseases (AFR/RC48/R2). Harare , Zimbabwe, September 1998

2 World Health Organization Regional Office for Africa and US Centers for Disease Control and Prevention.

“Technical Guidelines for Integrated Disease Surveillance Response in the African Region.” October 2010.

3 World Health Organization Regional Office for Africa and US Centers for Disease Control and Prevention.

“Technical Guidelines for Integrated Disease Surveillance Response in the African Region.” October 2010.

4 WHO, “The Implementation of Integrated Disease Surveillance and Response in the African and Eastern

Mediterranean Regions: Synthesis Report.” WHO, CDC, USAID, SARA, UNFIP, May 2003. Available at:

http://www.cdc.gov/idsr/focus/surv_sys_strengthening/doc_idsr_implement.pdf (accessed November 16, 2011).

5 WHO Regional Committee for Africa, “International Health Regulations (2005): Informational Document

(AFR/RC56/INF.DOC/2).” Addis Ababa, Ethiopia: AFRO, 31 July 2006.

6 World Health Organization, Regional Office for Africa, “Integrated Disease Surveillance: Technical Guidelines for

Integrated Disease Surveillance and Response in the Africa Region.” Available at:

http://www.afro.who.int/en/clusters-a-programmes/dpc/integrated-disease-surveillance/features/2775-technicalguidelines-for-integrated-disease-surveillance-and-response-in-the-african-region.html

(accessed August 11,

2011).

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IDSR/IHR Workshop Report

7 Centers for Disease Control and Prevention, “Current Status of Integrated Disease Surveillance and Response

(IDSR) in Countries.” Available at: http://www.cdc.gov/globalhealth/dphswd/idsr/progress/status.html (accessed

February 15, 2012)

8 Nsubuga, Peter, et al., "Public Health Surveillance: A Tool for Targeting and Monitoring Intervention," in Disease

Control Priorities in Developing Countries (2nd Edition), New York: Oxford University Press, 2006, 997-1018.

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