WEBVTT 00:00:00.000 --> 00:00:02.916 align:middle line:90% [MUSIC PLAYING] 00:00:02.916 --> 00:00:06.792 align:middle line:90% 00:00:06.792 --> 00:00:09.000 align:middle line:84% SVEA CLOSSER: Up to now throughout this whole section 00:00:09.000 --> 00:00:11.070 align:middle line:84% of the course, we've been considering 00:00:11.070 --> 00:00:15.190 align:middle line:84% surveillance for polio as if it existed in a vacuum. 00:00:15.190 --> 00:00:18.280 align:middle line:84% But polio is not the only surveillance need of countries 00:00:18.280 --> 00:00:20.680 align:middle line:90% like Nigeria and DRC. 00:00:20.680 --> 00:00:24.220 align:middle line:84% Many other diseases, from Ebola to measles to cancer, 00:00:24.220 --> 00:00:26.660 align:middle line:90% affect these populations. 00:00:26.660 --> 00:00:30.740 align:middle line:84% Polio eradication has an unmatched and unprecedented 00:00:30.740 --> 00:00:32.840 align:middle line:90% global surveillance system. 00:00:32.840 --> 00:00:36.380 align:middle line:84% The Global Polio Eradication headquarters in Geneva 00:00:36.380 --> 00:00:39.140 align:middle line:84% is responsible for polio surveillance and monitors 00:00:39.140 --> 00:00:41.420 align:middle line:84% and collects surveillance data on AFT 00:00:41.420 --> 00:00:43.880 align:middle line:90% from everywhere in the world. 00:00:43.880 --> 00:00:46.430 align:middle line:84% Overall, this system combines global reach 00:00:46.430 --> 00:00:48.440 align:middle line:84% and active surveillance quality in a way 00:00:48.440 --> 00:00:51.260 align:middle line:84% unmatched by any other system in the world 00:00:51.260 --> 00:00:55.350 align:middle line:84% and probably by any surveillance system in history. 00:00:55.350 --> 00:00:58.290 align:middle line:84% AFP surveillance systems across the world, as we've discussed, 00:00:58.290 --> 00:01:00.180 align:middle line:84% aren't perfect, but in general, they're 00:01:00.180 --> 00:01:04.440 align:middle line:84% characterized by high quality, active surveillance visits, 00:01:04.440 --> 00:01:08.340 align:middle line:84% extensive additional staff, often funded by WHO, 00:01:08.340 --> 00:01:12.120 align:middle line:84% and lab facility support, often constructed by the Polio 00:01:12.120 --> 00:01:14.140 align:middle line:90% Eradication Initiative. 00:01:14.140 --> 00:01:16.680 align:middle line:84% Though the exact mechanisms differ, 00:01:16.680 --> 00:01:19.920 align:middle line:84% the AFP surveillance systems are often managed by WHO staff 00:01:19.920 --> 00:01:22.260 align:middle line:84% at the national level and have historically 00:01:22.260 --> 00:01:24.990 align:middle line:84% had AFP surveillance as their sole focus 00:01:24.990 --> 00:01:28.400 align:middle line:84% or their primary focus in most countries. 00:01:28.400 --> 00:01:32.930 align:middle line:84% At the same time, right alongside this big huge global 00:01:32.930 --> 00:01:35.720 align:middle line:84% polio surveillance system, countries 00:01:35.720 --> 00:01:39.520 align:middle line:84% have surveillance systems for other diseases as well. 00:01:39.520 --> 00:01:42.360 align:middle line:84% And these systems across the whole world of course 00:01:42.360 --> 00:01:46.590 align:middle line:84% range widely in quality from excellent to completely 00:01:46.590 --> 00:01:47.990 align:middle line:90% defunct. 00:01:47.990 --> 00:01:49.770 align:middle line:84% And these systems generally have not 00:01:49.770 --> 00:01:51.810 align:middle line:84% gotten the international support and funding 00:01:51.810 --> 00:01:54.420 align:middle line:84% that has been given to polio surveillance. 00:01:54.420 --> 00:01:58.500 align:middle line:84% For example, the DRC system is adequate for a few diseases 00:01:58.500 --> 00:02:01.125 align:middle line:90% but not for many common killers. 00:02:01.125 --> 00:02:03.000 align:middle line:84% So if you think about the surveillance system 00:02:03.000 --> 00:02:05.940 align:middle line:84% in your own country, are there any other diseases that 00:02:05.940 --> 00:02:08.400 align:middle line:90% have as good a system as polio? 00:02:08.400 --> 00:02:10.199 align:middle line:84% And are there diseases whose systems really 00:02:10.199 --> 00:02:11.428 align:middle line:90% need strengthening? 00:02:11.428 --> 00:02:13.720 align:middle line:84% You may or may not know the answers to these questions. 00:02:13.720 --> 00:02:16.380 align:middle line:84% But in almost any country, there are some trade-offs. 00:02:16.380 --> 00:02:17.980 align:middle line:90% Surveillance is expensive. 00:02:17.980 --> 00:02:19.812 align:middle line:84% You can't do it for every disease. 00:02:19.812 --> 00:02:21.270 align:middle line:84% So countries have to make decisions 00:02:21.270 --> 00:02:23.380 align:middle line:90% about what they're going to do. 00:02:23.380 --> 00:02:26.280 align:middle line:84% So the issue here is that often for countries, funding 00:02:26.280 --> 00:02:28.650 align:middle line:84% may be available for polio surveillance in a way 00:02:28.650 --> 00:02:30.450 align:middle line:84% that it's not available for surveillance 00:02:30.450 --> 00:02:32.140 align:middle line:90% for other diseases. 00:02:32.140 --> 00:02:33.900 align:middle line:84% So in many countries, what's happened 00:02:33.900 --> 00:02:36.360 align:middle line:84% is you have this very high quality polio surveillance 00:02:36.360 --> 00:02:39.570 align:middle line:84% system that may coexist alongside not 00:02:39.570 --> 00:02:42.450 align:middle line:84% great surveillance systems for diseases that might kill way 00:02:42.450 --> 00:02:45.185 align:middle line:84% more people in a given population. 00:02:45.185 --> 00:02:46.810 align:middle line:84% Given this issue, it's really important 00:02:46.810 --> 00:02:48.760 align:middle line:84% to think about whether the polio surveillance 00:02:48.760 --> 00:02:51.670 align:middle line:84% system could be used to improve surveillance for other diseases 00:02:51.670 --> 00:02:52.970 align:middle line:90% too. 00:02:52.970 --> 00:02:56.680 align:middle line:84% And this doesn't directly benefit polio eradication, 00:02:56.680 --> 00:03:00.190 align:middle line:84% but it can have a huge impact on reducing morbidity 00:03:00.190 --> 00:03:02.500 align:middle line:84% and mortality from other diseases 00:03:02.500 --> 00:03:05.650 align:middle line:84% if countries can learn where these diseases are happening. 00:03:05.650 --> 00:03:07.120 align:middle line:84% So many countries across the world 00:03:07.120 --> 00:03:09.850 align:middle line:84% have been successful in building some additional disease 00:03:09.850 --> 00:03:12.800 align:middle line:84% surveillance onto the AFP system. 00:03:12.800 --> 00:03:19.180 align:middle line:84% So this particular graph here shows that, over time, 00:03:19.180 --> 00:03:20.860 align:middle line:90% in seven African countries-- 00:03:20.860 --> 00:03:24.490 align:middle line:84% Angola, DRC, Cote d'Ivoire, Ethiopia, Nigeria, Tanzania, 00:03:24.490 --> 00:03:26.080 align:middle line:90% and Togo-- 00:03:26.080 --> 00:03:29.530 align:middle line:84% more and more diseases were integrated into the polio 00:03:29.530 --> 00:03:31.130 align:middle line:90% surveillance system. 00:03:31.130 --> 00:03:34.570 align:middle line:84% So in the late '90s when the AFP surveillance system was 00:03:34.570 --> 00:03:36.530 align:middle line:84% relatively new in these countries, 00:03:36.530 --> 00:03:38.710 align:middle line:90% it was just looking for AFP. 00:03:38.710 --> 00:03:43.390 align:middle line:84% And 15 years later, by 2014, a lot of other diseases 00:03:43.390 --> 00:03:47.060 align:middle line:84% had also been integrated into the polio surveillance system 00:03:47.060 --> 00:03:51.490 align:middle line:84% in many cases, including things like measles, cholera, 00:03:51.490 --> 00:03:56.100 align:middle line:84% meningitis, rabies, issues that affect a lot of people. 00:03:56.100 --> 00:03:59.400 align:middle line:84% Despite this overlap, sometimes surveillance protocols 00:03:59.400 --> 00:04:02.940 align:middle line:84% for AFP and other diseases may not be fully integrated. 00:04:02.940 --> 00:04:04.500 align:middle line:84% For example, a surveillance system 00:04:04.500 --> 00:04:07.620 align:middle line:84% may use different monitoring and reporting personnel, protocols, 00:04:07.620 --> 00:04:09.750 align:middle line:84% and procedures to track suspected 00:04:09.750 --> 00:04:11.913 align:middle line:90% cases of various diseases. 00:04:11.913 --> 00:04:13.830 align:middle line:84% And this happened especially if those diseases 00:04:13.830 --> 00:04:17.649 align:middle line:84% have different internationally funded reporting requirements. 00:04:17.649 --> 00:04:19.410 align:middle line:84% So for example, measles, which has 00:04:19.410 --> 00:04:23.940 align:middle line:84% a different global initiative to eliminate cases, 00:04:23.940 --> 00:04:25.470 align:middle line:84% has its own reporting requirements 00:04:25.470 --> 00:04:27.640 align:middle line:84% that come from an international level. 00:04:27.640 --> 00:04:31.110 align:middle line:84% AFP has reporting requirements that come from the GPI 00:04:31.110 --> 00:04:32.410 align:middle line:90% and so on. 00:04:32.410 --> 00:04:34.620 align:middle line:84% So these different global requirements 00:04:34.620 --> 00:04:36.210 align:middle line:84% can make it difficult for countries 00:04:36.210 --> 00:04:39.440 align:middle line:84% to really integrate systems in a way that makes sense. 00:04:39.440 --> 00:04:42.180 align:middle line:84% And this can lead to a really inefficient use of worker time 00:04:42.180 --> 00:04:43.423 align:middle line:90% at the ground level. 00:04:43.423 --> 00:04:45.090 align:middle line:84% So you may have community health workers 00:04:45.090 --> 00:04:47.190 align:middle line:84% that are responsible for surveillance filling out 00:04:47.190 --> 00:04:49.140 align:middle line:84% completely different forms and sending them 00:04:49.140 --> 00:04:51.750 align:middle line:84% to completely different places for different diseases 00:04:51.750 --> 00:04:53.667 align:middle line:84% even though they're looking for these diseases 00:04:53.667 --> 00:04:55.330 align:middle line:90% in the same population. 00:04:55.330 --> 00:04:58.110 align:middle line:84% So frontline workers are critical in thinking 00:04:58.110 --> 00:05:01.230 align:middle line:84% about building good surveillance systems. 00:05:01.230 --> 00:05:03.435 align:middle line:84% And in Nigeria, building the capacity 00:05:03.435 --> 00:05:05.310 align:middle line:84% of these frontline workers to do surveillance 00:05:05.310 --> 00:05:08.820 align:middle line:84% has been something that polio eradication has focused on. 00:05:08.820 --> 00:05:12.260 align:middle line:84% So when they are doing campaigns, 00:05:12.260 --> 00:05:15.370 align:middle line:84% health care workers get trained on surveillance as well, 00:05:15.370 --> 00:05:18.090 align:middle line:84% particularly in conflict regions. 00:05:18.090 --> 00:05:21.720 align:middle line:84% And they're trained not just about surveillance of polio 00:05:21.720 --> 00:05:23.310 align:middle line:84% but surveillance of other diseases 00:05:23.310 --> 00:05:26.055 align:middle line:84% as well and also some information about the provision 00:05:26.055 --> 00:05:27.930 align:middle line:84% of health care services that they can pass on 00:05:27.930 --> 00:05:29.730 align:middle line:90% to community members. 00:05:29.730 --> 00:05:32.220 align:middle line:84% In Nigeria, the emergency operation center, 00:05:32.220 --> 00:05:36.720 align:middle line:84% which is designed to support polio eradication, 00:05:36.720 --> 00:05:38.580 align:middle line:84% has also been used by other disease control 00:05:38.580 --> 00:05:41.830 align:middle line:84% programs including when there was an Ebola epidemic. 00:05:41.830 --> 00:05:45.390 align:middle line:84% So there are ways that various countries have 00:05:45.390 --> 00:05:49.410 align:middle line:84% built other surveillance capacity onto the polio system, 00:05:49.410 --> 00:05:53.100 align:middle line:84% but it tends to be on the initiative of the countries 00:05:53.100 --> 00:05:56.557 align:middle line:84% themselves and wasn't built into the way 00:05:56.557 --> 00:05:58.140 align:middle line:84% that the polio surveillance system was 00:05:58.140 --> 00:06:00.180 align:middle line:90% designed from the start. 00:06:00.180 --> 00:06:02.130 align:middle line:84% Beyond frontline staff, there's also 00:06:02.130 --> 00:06:04.800 align:middle line:84% been an effort to build capacity in Nigeria 00:06:04.800 --> 00:06:07.560 align:middle line:84% for other kinds of surveillance staff. 00:06:07.560 --> 00:06:09.990 align:middle line:84% So the African Field Epidemiology and Laboratory 00:06:09.990 --> 00:06:12.000 align:middle line:84% Training Program trains field workers 00:06:12.000 --> 00:06:14.370 align:middle line:90% across levels of the system. 00:06:14.370 --> 00:06:17.670 align:middle line:84% And NGOs in Nigeria have been conducting training 00:06:17.670 --> 00:06:21.390 align:middle line:84% for a variety of staff participating in campaigns 00:06:21.390 --> 00:06:23.008 align:middle line:90% and also in surveillance. 00:06:23.008 --> 00:06:25.050 align:middle line:84% At a more basic level, there's been some training 00:06:25.050 --> 00:06:27.310 align:middle line:90% at universities as well. 00:06:27.310 --> 00:06:31.373 align:middle line:84% Similarly in the DRC, in collaboration with the CDC, 00:06:31.373 --> 00:06:32.790 align:middle line:84% two programs have been established 00:06:32.790 --> 00:06:34.770 align:middle line:90% to train disease detectives. 00:06:34.770 --> 00:06:37.230 align:middle line:84% At universities, there's now a two year MPH 00:06:37.230 --> 00:06:38.970 align:middle line:84% in field epidemiology and laboratory 00:06:38.970 --> 00:06:41.130 align:middle line:84% training and an accelerated training 00:06:41.130 --> 00:06:43.197 align:middle line:90% program for frontline workers. 00:06:43.197 --> 00:06:45.030 align:middle line:84% These trained disease detectives collaborate 00:06:45.030 --> 00:06:47.880 align:middle line:84% with the Ministry of Health and WHO to search for 00:06:47.880 --> 00:06:51.790 align:middle line:84% and investigate cases of AFP in areas with outbreaks. 00:06:51.790 --> 00:06:54.600 align:middle line:84% And they've been instrumental in containing these outbreaks 00:06:54.600 --> 00:06:56.540 align:middle line:90% in a timely way. 00:06:56.540 --> 00:06:58.880 align:middle line:84% It can be challenging to really integrate 00:06:58.880 --> 00:07:02.090 align:middle line:84% polio and national surveillance systems. 00:07:02.090 --> 00:07:04.910 align:middle line:84% Sometimes countries have been reluctant to rely too much 00:07:04.910 --> 00:07:07.070 align:middle line:84% on the AFP surveillance system because it's seen 00:07:07.070 --> 00:07:09.380 align:middle line:90% as inherently unsustainable. 00:07:09.380 --> 00:07:12.740 align:middle line:84% Given that it's supported nearly entirely by external funding 00:07:12.740 --> 00:07:15.830 align:middle line:84% and that external funding is tied to polio, 00:07:15.830 --> 00:07:18.440 align:middle line:84% some countries fear that once polio is eradicated, 00:07:18.440 --> 00:07:20.780 align:middle line:84% the surveillance system will disappear. 00:07:20.780 --> 00:07:22.370 align:middle line:84% They also fear if they build too much 00:07:22.370 --> 00:07:24.740 align:middle line:84% of their other surveillance onto the system, 00:07:24.740 --> 00:07:27.260 align:middle line:84% those surveillance systems for other diseases 00:07:27.260 --> 00:07:30.300 align:middle line:84% might also be hurt if polio goes away. 00:07:30.300 --> 00:07:34.060 align:middle line:84% So in many countries with very, very weak surveillance systems, 00:07:34.060 --> 00:07:36.740 align:middle line:84% the WHO created a high quality parallel 00:07:36.740 --> 00:07:39.140 align:middle line:90% system for polio surveillance. 00:07:39.140 --> 00:07:41.750 align:middle line:84% But often a lot of other diseases 00:07:41.750 --> 00:07:43.820 align:middle line:84% weren't included in that because of the fear 00:07:43.820 --> 00:07:45.350 align:middle line:84% that the system might deteriorate 00:07:45.350 --> 00:07:47.700 align:middle line:84% in the absence of foreign investment. 00:07:47.700 --> 00:07:50.000 align:middle line:84% So DRC is one example of the challenges 00:07:50.000 --> 00:07:51.920 align:middle line:90% of a parallel system. 00:07:51.920 --> 00:07:54.920 align:middle line:84% Because the polio system was focused on polio 00:07:54.920 --> 00:07:57.800 align:middle line:84% and not other vaccine preventable diseases, 00:07:57.800 --> 00:08:00.260 align:middle line:84% remaining coverage gaps in routine immunization 00:08:00.260 --> 00:08:04.940 align:middle line:84% have left the DRC susceptible to vaccine-derived polio. 00:08:04.940 --> 00:08:07.040 align:middle line:84% Without continued investment, and improving 00:08:07.040 --> 00:08:09.380 align:middle line:84% routine immunization, and maintaining disease 00:08:09.380 --> 00:08:12.080 align:middle line:84% surveillance systems for a range of vaccine-preventable 00:08:12.080 --> 00:08:16.050 align:middle line:84% diseases, it's been difficult to eradicate polio. 00:08:16.050 --> 00:08:19.660 align:middle line:84% The takeaway here is that future initiatives should consider 00:08:19.660 --> 00:08:22.690 align:middle line:84% ways to leverage their program resources to improve health 00:08:22.690 --> 00:08:25.510 align:middle line:84% systems in a broad way rather than drawing 00:08:25.510 --> 00:08:28.660 align:middle line:84% internal resources away from other health priorities. 00:08:28.660 --> 00:08:31.480 align:middle line:84% In addition, vertical disease control programs 00:08:31.480 --> 00:08:35.169 align:middle line:84% should be careful about creating alternate structures which 00:08:35.169 --> 00:08:37.000 align:middle line:84% temporarily maintain health system 00:08:37.000 --> 00:08:40.179 align:middle line:84% functions without enabling the requirements for sustaining 00:08:40.179 --> 00:08:42.909 align:middle line:84% those functions once program goals are met. 00:08:42.909 --> 00:08:45.345 align:middle line:90% This is a challenging mandate. 00:08:45.345 --> 00:08:46.720 align:middle line:84% And that's why it hasn't happened 00:08:46.720 --> 00:08:50.110 align:middle line:84% in a lot of vertical programs but it's particularly important 00:08:50.110 --> 00:08:53.260 align:middle line:84% when working in contexts with relatively weak health systems. 00:08:53.260 --> 00:08:56.910 align:middle line:90% [MUSIC PLAYING] 00:08:56.910 --> 00:09:01.000 align:middle line:90%