Humanitarian Led Community-based Surveillance: Case Study in Ekondo-titi, Cameroon

"Humanitarian actors should explore the use of CBS in humanitarian responses to improve disease surveillance and contribute in strengthening health systems."

Community-based surveillance (CBS) - the systematic detection and reporting of events of public health significance by community members - has been used in many situations to strengthen existing health systems, as well as in humanitarian crises. Developed to overcome logistical difficulties of travel and communication, which are common in low- and middle-income countries (LMICs), CBS is an alternative to the conventional surveillance system whereby epidemiologists visit sites to discover and investigate cases (e.g., of polio). The 2016 "Anglophone Crisis" of Northwest Southwest (NWSW) regions of Cameroon led to burning of villages, targeting of health personnel, and destruction of health facilities; in combination with distrust of government services, this crisis led to a collapse of surveillance for outbreak-prone diseases (OPDs). This paper discusses a one-year project incorporating CBS called Rapid Response Mechanism (RRM+) for timely emergency response to displaced communities in hard-to-reach areas within Ekondo-titi health district, Cameroon.

The Office for the Coordination of Humanitarian Affairs (OCHA) estimated that, due to the conflict, by December 2019, 679,000 people were internally displaced in NWSW Cameroon. Prior to 2016, the Ekondo-titi health district had 13 health facilities and one hospital serving a population of 56,503 inhabitants; by March 2019, the number of functional health facilities had dropped to 4. Surveillance, which relied upon health facility reporting, deteriorated in the health district, as it did across NWSW Cameroon. In 2019, 9 health districts in the Southwest did not report a single suspected case of measles, neonatal tetanus, yellow fever, or acute flaccid paralysis (AFP - for polio); within Ekondo-Titi health district, no suspected cases were identified in 2015, 2016, 2017, and 2018. This lack of reports is most likely due to reduced surveillance rather that true lack of outbreaks, as there were also no false reports.

To address this situation, Reach Out NGO, with support from the United Nations Children's Fund (UNICEF), set up a CBS system as part of the RRM+ project in Ekondo-titi. It was operational from July 2019 to April 2020, although the RRM+ project itself started in April 2019. The evaluation was carried out after the end of the project, from May 2020 to June 2020.

For the RRM+, community health workers (CHWs) were the main field agents at the community level, as they were community members who had been internally displaced with the affected populations. CHWs were expected to report suspected cases of OPD and other public health events. Suspected cases of measles, cholera, meningitis, neonatal tetanus, and AFP were reported immediately through a phone call or text message on the CHW's personal phone. In some cases, in the absence of cell service, CHWs walked, sometimes as far as 20 kilometres, to the Reach Out field office to report a case. On receipt of this information by the mobile health team (MHT) and completion of verification, national reporting tools were completed and submitted to the District Health Service (DHS).

In response to all OPD alerts, the MHT - made up of a medical doctor, 2 nurses, and a protection officer - conducted a field investigation mission, collected samples, and carried out a community response for all confirmed and all suspected outbreaks. These steps represented an additional utility of the system, given that health centres in the districts were not functional, and the DHS doesn't normally have any allocated resources for an investigation and response. Though the main benefit package was health delivery, the needs of populations in humanitarian settings had to be tackled from a holistic approach. Thus, the project also included nutrition, child protection, and water, sanitation, and hygiene (WASH) components.

In total, 9 alerts of suspected OPDs were generated by the CBS system as compared to 0 by the DHS, with 8 investigated, 5 responses, and 3 confirmed outbreaks. The average time from first symptoms to alert generation by the CBS system was 7.3 days, and the average time lag from alert generation from the CBS to the DHS was 0.3 days (essentially within 24 hours).

The paper shares the results of interventions undertaken to contain suspected/confirmed outbreaks. For example, in the case of a measles outbreak detected by the CBS alert and subsequent MHT investigation, the MHT mobilised CHWs in communities within the affected health areas and other neighbouring communities - informing them of the outbreak and the need for an emergency ring vaccination campaign. No further cases of measles were identified after 317 children were vaccinated as part of this campaign.

According to organisers, the use of CHWs living as part of the displaced communities increased community acceptance and engagement of the communities in mass immunisation services, even at short notice. Most of the outbreaks occurred in extremely hard-to-reach communities, where there was little to no government access, including new internally displaced person (IDP) settlements in bushes. (Displacement monitoring was carried out as part of the CBS. This was of particular importance in this setting, as data about current population figures were lacking, and repeated and pendular displacement was common.)

Throughout the intervention, there was extensive and synergistic collaboration with the DHS. However, local health administrators were unused to working with humanitarian actors, and initial relationships were challenging, especially with regard to outbreak reporting. As the districts reporting had been mostly silent, the sudden influx of diseases identified when humanitarian actors began working was viewed negatively. This relationship challenge required regular and extensive engagement - e.g., informing the local district authorities on all suspected cases and involving them in the response by updating them regularly.

Insecurity, poor telecommunication signals, and bad roads were the most common challenges reported by CHWs and the MHT. The safety of CHWs in this project was treated with utmost importance due to frequent security incidences in Ekondo-titi. First, all CHWs were trained on safety and security and humanitarian principles to enable them have foresight on what to do when faced with a security threat. Access negotiations and mediations were done with both the government and community leaders on behalf of the CHWs and the MHT. CHWs were told to always wear their badges and project jackets for easy identification.

In sum, the CBS generated a higher number of alerts than traditional outbreak reporting used in the region and had timely investigations and if appropriate, responses. Careful selection of CHWs with strong community engagement contributed to what organisers consider the success of the project, and the use of the MHT in situ allowed for rapid responses to potential outbreaks, as well as for feedback to CHWs and communities. CBS was also well utilised for identification of other events, such as displacement and malnutrition.

In conclusion: "The extensive acceptance gained through the active participation and collaboration with communities through the service delivery offered as part of the RRM+ model, allowed for community acceptance of the CBS system, and led to safer assess for humanitarian organizations to work....Without the other aspects of the project, such as WASH, child protection, health and nutrition, the CBS system would not have been so readily accepted."