Moving Africa's Vaccine-Preventable Disease Surveillance From Epi Info to DHIS2

This report describes the transition as of February 2024.

Good, timely surveillance data on vaccine-preventable diseases (VPDs) are what let health officials spot cases and outbreaks and respond quickly. In the World Health Organization's African Region, those data were long managed in Epi Info, a free statistical package CDC first released in 1985, at district, provincial, national and regional levels. The Epi Info system suffered from reporting delays and could not connect with other information systems.

District Health Information Software 2 (DHIS2), developed at the University of Oslo, is a free, open-source and fully customizable health information system built to connect with other systems. About 80 low- and middle-income countries use it. In 2019, a WHO African Regional Office (AFRO) consultation recommended it as the region's VPD surveillance platform. In 2023, AFRO also launched Ending Disease in Africa (ENDISA), a strategy that stresses data-driven public health built on integrated data and advanced analytics.

Two packages

AFRO and its partners built two DHIS2 packages to replace the centralized, offline Epi Info system:

• an aggregate Integrated Disease Surveillance and Response (IDSR) package for weekly counts of epidemic-prone diseases, which countries can extend beyond the diseases required under the International Health Regulations;
• a case-based surveillance package for individual reports of nine notifiable VPDs, linking each case's clinical, laboratory, investigation and outcome data.

Both are web-based and usable anywhere with an internet connection, allowing near real-time reporting of suspected cases. They can send automatic text or email alerts to a set list of people, and pass data to other DHIS2 packages when outbreak thresholds are crossed. They also sync automatically with the regional platform, combine reporting on many diseases in one database, and give districts and provinces better access to the data.

Three phases

1. 2019–2021, building and piloting. Teams defined requirements, set up databases, permissions, data elements, forms and user roles, and piloted the packages in Mali, Rwanda and Togo. Each country chose which diseases and data elements to report, following national guidelines and regional requirements.
2. 2022, expanding. The packages were rolled out to more countries, and AFRO built a DHIS2 regional data platform to replace Epi Info as the store for all VPD data from the region. It sits within a regional data warehouse whose data can be shared with portals such as WHO's Immunization Information System.
3. 2023 onward, building capacity. Training, technical help and monitoring to get countries reporting to the regional platform, with the pilot countries sharing what they learned.

Where things stood in February 2024

Of the 47 countries in the region:

• IDSR package: 29, including the three pilots, had fully implemented it nationwide, and four more were testing it.
• Case-based package: eight, including the three pilots, had implemented it in all districts; seven had it in selected districts; six were testing it.
• Both packages: eight had fully adopted both at the national level.
• Regional reporting: two had successfully sent aggregate data to the regional platform with the DHIS2 data transfer app. None of the countries using non-DHIS2 systems had been trained or attended an onboarding workshop, so none had transferred data with the import tool designed for them.

At a March 2023 onboarding workshop, seven countries drew up plans to connect their national systems to the regional platform. They reported that mapping data from Epi Info to DHIS2 was slow, that they needed technical help where data elements and organizational units did not match, and that they needed training at national and subnational levels. Some asked AFRO for formal procedures on communication and data sharing.

Challenges ahead

Countries can often draw on staff and money from other funded programs for their own surveillance data, but no comparable dedicated resources exist for regional VPD reporting to AFRO. Without funding and staff able to customize and configure the system, the authors warn, the transition will be delayed and timely, accurate reporting hindered. Data-sharing agreements with reporting countries are also needed. AFRO is writing operational guidance and standard operating procedures, and the authors call for a regional transition plan with a clear roadmap, resources and timeline.

The status figures are self-reported by countries, not verified, and not routinely updated, and the feedback came only from the seven workshop countries.

Sources

• Adegoke OJ, Rachlin A, Porter AM, et al. Migration from Epi Info to District Health Information Software 2 for Vaccine-Preventable Disease Surveillance — World Health Organization African Region, 2019–2023. MMWR Morb Mortal Wkly Rep 73(23). https://www.cdc.gov/mmwr/volumes/73/wr/mm7323a2.htm
• DHIS2 overview: https://dhis2.org/overview/
• The report was written jointly by CDC, WHO and the University of Oslo; its figures are not reproduced here.