1. Overview of the Early Warning and Response System (EWARS)
The World Health Organization (WHO) in collaboration with the Ministry of Health and Family Welfare (MOHWF) established a disease early warning and response system (EWARS) in Cox’s Bazar district, Chittagong division in Bangladesh as a response to the influx of Forcibly Displaced Myanmar Nationals (FDMN) in early September 2017.
The overall goal of EWARS is to minimize mortality and morbidity due to communicable diseases. EWARS’ objective is to detect potential outbreaks. Disease reporting through EWARS began in October 2017. EWARS is composed of five components, goal setting, information collection, data analysis, information distribution, and early warning response. Standardized case definitions and reporting forms were developed and distributed (in consultation with all health partners to maximize acceptance and widely distributed in paper form and electronically).
District and national surveillance staff members were oriented trained on the case dentitions of events under EWRAS, filling the reporting forms, flow of data and reporting mechanisms. Fixed health facilities and mobile clinics throughout Cox’s Bazar are requested to report case counts of 18 conditions considered to be either epidemic-prone or of public health importance1 . Information is compiled daily at the civil surgeon’s control room and the Morbidity and Mortality Weekly Bulletin (MMWB) is issued on a weekly basis. EWARS includes an immediate disease alert and response component to meet its primary objective. Most diseases in EWARS have a defined alert threshold that triggers action.
So EWARS investigates several alerts including measles, tetanus, diphtheria, and acute jaundice syndrome through field investigation teams, depending on the suspected agents, clinical review of the cases, contact tracing, active case finding and sampling for laboratory investigation. As part of the investigation, limited containment interventions might take place including health education and distribution of water purification tablets.
Daily reporting began on 2 October 2017. The average number of reporting forms fluctuated between 1 and 4 daily reports in the first 4 weeks. By September 2017, the average reached more than 55 reports per day. By now, EWARS is covering all 11 FDMNs settlements’ and the host population in Cox’s Bazar district.
During its rapid implementation, EWARS faced several challenges. Firstly, various non-standard reporting forms were used by different health partners and acceptance of the standardized reporting forms was limited. The latter was due to the fact that some diseases that were considered important by health authority were not included in the EWARS forms (skin diseases and eye infections). To avoid multiple nonstandard forms, these events were included in the EWARS form.
Second, lack of reliable information on functioning health facilities and their catchment populations such as mobile clinics. Third, reporting sites fluctuated daily and late or missing reports were difficult to track. A spreadsheet was developed and daily contact with health partners was established to follow up missing forms.
2. Population under Surveillance and Reporting Units
During epidemiological week 47 (19-25 November 2017), there was a 0.4% increase in the population2 under EWARS compared to the previous epidemiological week (826,278 and 823,084 respectively). The Kutupalong makeshift camp population decreased by 0.07% (441,623 vs 441,300), mainly due to the ongoing relocation of FDMNs from other camps and settlements. The remaining camp population remained more or less stable.
The population of the settlements fluctuates daily due to movements between camps and new arrivals. For this reason, it was difficult to estimate the actual catchment population covered by the medical mobile teams working in camps and settlement areas.
EWARS reports were received from partner agencies active in the field in all the FDMNs Makeshift settlements and new spontaneous camps namely: Kutupalong Expansion, Kutupalong registered camp, Leda registered camp, Nyapara registered camp, Shamlapur, Hakimpara, Thangkhal, Unchiprang, Jamtoli, and Moynarghona. In addition, EWARS data forms were collected from different departments (admission, emergency, surgery, paediatrics, gynaecology and internal medicine) of Cox’s Bazar Sadar hospital and Teknaf and Ukhia Health Complexes (population of 100,400).
During epidemiological week 47, the number of daily reports per camp/settlement in Cox’s Bazar decreased by 6% compared with the previous week (from 419 to 440 reports). Table 1 below shows the population per camp and the daily number of EWARS reporting forms submitted from each of them.