Gunnar Bjune

Background: Facing the threats of emerging and reemerging health issues requires One Health surveillance systems to provide information for integrated responses. Malawi started enhancing the electronic integrated disease surveillance and response (eIDSR) system in 2015, progressing with the aim of developing a One Health Surveillance Platform (OHSP) using District Health Information Software 2 (DHIS2) as its technical backbone, thereby supporting the COVID-19 pandemic response more resiliently and impacting the integrated disease surveillance and response (IDSR) performance. Digital solutions are critical components of One Health surveillance; however, evidence of the successful establishment and implementation of adaptive digital One Health surveillance systems is scarce. Objective: This study aims to report on the establishment of the OHSP in Malawi and how an adaptive digital health solution contributed to strengthening and impacting the country’s eIDSR during the COVID-19 pandemic and beyond the pandemic. Methods: The establishment of Malawi’s OHSP was based on the action design research methodology with a transdisciplinary approach. The core team reflected the multiple iterative processes of building the OHSP and formalized its impact on IDSR reporting quality. Results: The OHSP core team conducted multiple iterative cycles to build the platform, leveraging lessons from previous eIDSR pilots, reusing digital health infrastructure, and developing DHIS2 digital solutions in 2019, right before the COVID-19 pandemic. The initial establishment was to cover 48.3% (14/29) of the country’s health districts. Pivoting from the initial plan as the COVID-19 pandemic emerged, the core team swiftly adapted the OHSP to scale up nationwide and assisted the health system in responding to the pandemic. The pandemic shock resulted in a national scale-up of the OHSP and impacted the national weekly IDSR reporting quality from nonexistence in 2015 to 97.8% and 74.5% for completeness and timeliness, respectively, in 2024. Conclusions: The establishment of the OHSP significantly bolstered the surveillance function for weekly IDSR reporting. Government leadership and good coordination were key to success. Continuous capacity building, enhancement of community-level surveillance with digital innovations, adaptable technical infrastructure, and a reuse strategy can provide long-term sustainability for One Health surveillance. Malawi’s experience may apply to other countries with demonstrated value of resilient, government-led digital health interventions. Future efforts should focus on improving interoperability with other One Health domains and investing in infrastructure upgrades with local leadership and domestic funding to prepare for future emergencies.

BACKGROUND Facing the threats of emerging and reemerging health issues requires One Health surveillance systems to provide information for integrated responses. Malawi started enhancing the electronic integrated disease surveillance and response (eIDSR) system in 2015, progressing with the aim of developing a One Health Surveillance Platform (OHSP) using District Health Information Software 2 (DHIS2) as its technical backbone, thereby supporting the COVID-19 pandemic response more resiliently and impacting the integrated disease surveillance and response (IDSR) performance. Digital solutions are critical components of One Health surveillance; however, evidence of the successful establishment and implementation of adaptive digital One Health surveillance systems is scarce. OBJECTIVE This study aims to report on the establishment of the OHSP in Malawi and how an adaptive digital health solution contributed to strengthening and impacting the country’s eIDSR during the COVID-19 pandemic and beyond the pandemic. METHODS The establishment of Malawi’s OHSP was based on the action design research methodology with a transdisciplinary approach. The core team reflected the multiple iterative processes of building the OHSP and formalized its impact on IDSR reporting quality. RESULTS The OHSP core team conducted multiple iterative cycles to build the platform, leveraging lessons from previous eIDSR pilots, reusing digital health infrastructure, and developing DHIS2 digital solutions in 2019, right before the COVID-19 pandemic. The initial establishment was to cover 48.3% (14/29) of the country’s health districts. Pivoting from the initial plan as the COVID-19 pandemic emerged, the core team swiftly adapted the OHSP to scale up nationwide and assisted the health system in responding to the pandemic. The pandemic shock resulted in a national scale-up of the OHSP and impacted the national weekly IDSR reporting quality from nonexistence in 2015 to 97.8% and 74.5% for completeness and timeliness, respectively, in 2024. CONCLUSIONS The establishment of the OHSP significantly bolstered the surveillance function for weekly IDSR reporting. Government leadership and good coordination were key to success. Continuous capacity building, enhancement of community-level surveillance with digital innovations, adaptable technical infrastructure, and a reuse strategy can provide long-term sustainability for One Health surveillance. Malawi’s experience may apply to other countries with demonstrated value of resilient, government-led digital health interventions. Future efforts should focus on improving interoperability with other One Health domains and investing in infrastructure upgrades with local leadership and domestic funding to prepare for future emergencies.

Background Traditional Healers (THs) hold significant roles in many developing countries, often sought for ailments like tuberculosis (TB). However, their knowledge, attitude, and practice (KAP) regarding TB, particularly in Ethiopia’s pastoralist areas, remains unexamined. This study evaluates THs’ KAP on TB and their perceptions to collaborate with conventional health systems on TB control. Method A cross-sectional survey was conducted among THs in Kereyu, Ethiopia from September 2014 to January 2015. Using a semi-structured questionnaire, 268 THs were interviewed. Health Extension workers helped identify the THs. Results Of the 268 participants, 80.6% were male. 97.4% were aware of TB (locally “dukubba soombaa”), with 80.2% associating its cause to proximity with a TB patient. Coughing for over two weeks was identified as a primary TB symptom by 87.35%. However, 66.4% displayed limited biomedical knowledge on TB. A notable 38.4% associated TB with sadness and hopelessness, while 47.8% utilized plant-based remedies for treatment. Impressively, 86.2% expressed willingness to collaborate with conventional health services for TB control. Conclusion The THs had limited biomedical knowledge and some misconceptions about TB. Despite providing traditional medicine to treat TB, their readiness to collaborate with established health systems is promising. Thus, Ethiopian TB control initiatives should consider integrating THs via targeted training and health education interventions.

Pastoralists rely on traditional healers (THs) for general health problems. However, some studies indicate that such practices result in delays in the diagnosis and treatment of tuberculosis (TB) cases. This study aims to assess the role of traditional healers in the detection and referral of active TB cases in a pastoralist community. We identified 22 traditional healers from 7 villages of Kereyu pastoralist community in the Fentale district in Ethiopia in January 2015. We trained these THs in identifying presumptive TB symptoms and early referral to the nearby healthcare facilities. The training was held during a 1 week period that included a visit to their villages and follow-up. A 1 day meeting was held with the traditional healers, the district TB care and prevention coordinator and health extension workers from the selected sub-district to discuss the referral link between THs and the nearby healthcare facilities. Health providers working at the TB units in the selected healthcare facilities were oriented about the training given and planned involvement of THs in referring presumptive TB case. In addition, documentation of the presumptive TB cases was discussed. We succeeded in tracing and interviewing 8 of the 22 THs. The rest were on seasonal migration. According to the THs report for the 1 year period, these 8 THs had referred 24 TB suspects to the healthcare facilities. Sputum smear microscopy confirmed 13 of the 24 suspects as having TB cases. Among those confirmed, 10 completed treatment and three were on treatment. Five presumptive TB cases were confirmed non TB cases through further evaluation at the healthcare facilities and six of the presumptive TB cases were lost to follow up by the THs. Whereas, four of the presumptive TB cases were lost to follow up to the healthcare facility. Results of the present study indicate that THs can contribute to the detection of undiagnosed active TB cases in a pastoralist community, provided they are given appropriate training and support.

Objective: The emerging and recent 2014 Ebola Virus Disease (EVD) outbreaks rang the bell to call upon efforts from globe to assist resource-constrained countries to strengthen public health surveillance system for early response. Malawi adopted the Integrated Disease Surveillance and Response (IDSR) strategy to develop its national surveillance system since 2002 and revised its guideline to fulfill the International Health Regulation (IHR) requirements in 2014. This study aimed to understand the state of IDSR implementation and differences between guideline and practice for future disease surveillance system strengthening. Methods: This was a mixed-method observational study. Quantitative data were to analyze completeness and timeliness of surveillance system performance from national District Health Information System 2 (DHIS2). Qualitative data were collected through interviews with 29 frontline health service providers from the selected district and key informants of the IDSR system implementation and administration at district and national levels. Findings: The current IDSR system showed relatively good completeness (76.4%) but poor timeliness (41.5%) of total expected monthly reports nationwide and zero weekly reports. The challenges of IDSR implementation revealed through qualitative data included lack of supervision, inadequate resources for training and difficulty to implement weekly report due to overwhelming paperwork at frontline health services. Conclusions: The differences between IDSR technical guideline and actual practice were huge. The developing information technology infrastructure in Malawi and emerging mobile health (mHealth) technology can be opportunities for the country to overcome these challenges and improve surveillance system to have better timeliness for the outbreaks and unusual events detection.

Tuberculosis (TB) is a major public health concern in the developing world. Early diagnosis and prompt initiation of treatment is essential for effective TB control. The aim of this study was to determine the length and analyze associated factors of patients’ and health system’s delays in the diagnosis and treatment of new pulmonary TB (PTB) patients. A cross-sectional study was conducted in 30 randomly selected public health facilities in West Gojjam Zone, Amhara Region, Ethiopia. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study. Patients’ delay (the time period from onset of TB symptoms to first presentation to a formal health provider) and health system’s delay (the time period from first presentation to a formal health provider to first start of TB treatment) were measured. Median patients’ and health system’s delays were calculated. Mixed effect logistic regression was used to analyze predictors of patients’ and health system’s delays. Seven hundred six patients were enrolled in the study. The median patients’ delay was 18 days (interquartile range [IQR]: 8–34 days) and the median health system’s delay was 22 days (IQR: 4–88 days). Poor knowledge of TB (adjusted odds ratio [AOR], 2.33; 95 % confidence interval [CI], 1.34–4.05), first visit to non-formal health provider (AOR, 47.56; 95 % CI, 26.31–85.99), self-treatment (AOR, 10.11; 95 % CI, 4.53–22.56) and patients’ age (≥45 years) (AOR, 2.99; 95 % CI, 1.14–7.81) were independent predictors of patients’ delay. Smear-negative TB (AOR, 1.88; 95 % CI, 1.32–2.68) and first visit to public health centers (AOR, 2.22; 95 % CI, 1.52–3.25) and health posts (AOR, 5.86; 95 % CI, 1.40–24.39) were found to be independent predictors of health system’s delay. The health system’s delay in this study was long and contributed more than 50 % of the total delay. Better TB diagnostic tools to complement sputum smear microscopy are needed to early diagnose PTB cases at peripheral health facilities. In addition, due emphasis should be given to increase public awareness about symptoms and consequences of TB disease.

The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services. This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program. A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient’s inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system. The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.

There is growing evidence suggesting that diabetes mellitus (DM) affects disease presentation and treatment outcome in tuberculosis (TB) patients. This study aimed at investigating the role of DM on clinical presentations and treatment outcomes among newly diagnosed TB patients. A prospective cohort study was conducted in South-Eastern Amhara Region, Ethiopia from September 2013 till March 2015. Study subjects were consecutively recruited from 44 randomly selected health facilities in the study area. Participants were categorized into two patient groups, namely, patients with TB and DM (TBDM) and TB patients without DM (TBNDM). Findings on clinical presentations and treatment outcomes were compared between the two patient groups. Cox proportional hazard regression analysis was applied to identify factors associated with death. Out of 1314 TB patients enrolled in the study, 109 (8.3 %) had coexisting DM. TBDM comorbidity [adjusted hazard ratio (AHR) 3.96; 95 % confidence interval (C.I.) (1.76–8.89)], and TB coinfection with human immunodeficiency virus (HIV) [AHR 2.59; 95 % C.I. (1.21–5.59)] were associated with increased death. TBDM and TBNDM patients did not show significant difference in clinical symptoms at baseline and during anti-TB treatment period. However, at the 2nd month of treatment, TBDM patients were more symptomatic compared to patients in the TBNDM group. The study showed that DM is associated with increased death during TB treatment. DM has no association with clinical presentation of TB except at the end of the intensive phase treatment. Routine screening of TB patients for DM is recommended for early diagnosis and treatment of patients with TBDM comorbidity.

QuantiFERON-TB Gold In-Tube® (QFT-GIT) test is used for the diagnosis of latent tuberculosis (TB) infection. Besides, QFT-GIT test could allow tracking changes in immune response among TB patients and their contacts. In high TB burden settings, reports on QFT-GIT conversions and reversions among TB patients and their contacts are limited. As part of a major project to study immune responses to TB infection, we investigated QFT-GIT test conversions and reversions among smear positive pulmonary TB patients and their household contacts over 12 months. We followed a total of 107 HIV negative participants (33 patients and 74 contacts) in Addis Ababa. We did QFT-GIT test at baseline and 12 months later according to the manufacturer’s instructions. At baseline, 25/33 (75.8%) of the patients and 50/74 (67.6%) of the contacts were QFT-GIT positive. At 12 months, 2 more patients (1 test negative and 1 indeterminate) became test positive. Besides, 11/24 (45.8%) test negative contacts became positive. Only one patient and one contact who were test positive at baseline became test negative 12 months later. At 12 months, the proportions of QFT-GIT test positives for patients and contacts were, therefore, 78.8% and 81.1%, respectively. Among contacts, the proportion of QFT-GIT test positives at 12 months was significantly higher compared to the corresponding proportion at baseline (McNemar, p = 0.006); similarly, the median IFN-γ response significantly increased at 12 months compared with the baseline level (Wilcoxon matched-pairs signed rank test, p = 0.01). Patients, however, had comparable median IFN-γ levels at baseline and 12 months later (p = 0.56). Nearly half of QFT-GIT negative household contacts at baseline became positive at 12 months. This suggests that repeated screening of QFT-GIT negative contacts may be needed for epidemiological studies and interventions of latent TB in an endemic setting. A large longitudinal study may be needed to confirm our observations.

Early detection and treatment of TB is essential for the success of TB control program performance. The aim of this study was to determine the length and analyze predictors of patients’, health systems’ and total delays among patients attending a referral hospital in Bahir Dar, Ethiopia.