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Case study

Delayed outbreak detection: a wake-up call to evaluate a surveillance system

Delayed outbreak detection: a wake-up call to evaluate a surveillance system

Lilian Bulage1,2,3,&, Daniel Kadobera1,3, Benon Kwesiga1,3, Steven Ndugwa Kabwama4, Alex Riolexus Ario1,3, Julie Rebecca Harris5,6


1Uganda National Institute of Public Health, Kampala, Uganda, 2African Field Epidemiology Network, Kampala, Uganda, 3Ministry of Health, Kampala, Uganda, 4College of Health Sciences, Makerere University School of Public Health, Kampala, Uganda, 5United States Centers for Disease Control and Prevention, Kampala, Uganda, 6Division of Global Health Protection, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, United States of America



&Corresponding author
Lilian Bulage, Uganda National Institute of Public Health, P.O Box 7272, Kampala, Uganda




During May, 83 of the 120 districts in Uganda had reported malaria cases above the upper limit of the normal channel. Across all districts, cases had exceeded malaria normal channel upper limits for an average of six months. Yet no alarms had been raised! Starting in 2000, Uganda adopted the World Health Organization (WHO) Integrated Disease Surveillance and Response (IDSR) strategy for disease reporting, including for malaria. Even early on, however, it was unclear how effectively IDSR and DHIS2 were being used in Uganda. Outbreaks were consistently detected late, but the underlying cause of the late detection was unclear. Suspecting there might be gaps in the surveillance system that were not immediately obvious, the Uganda FETP was asked to evaluate the malaria surveillance system in Uganda. This case study teaches trainees in Field Epidemiology and Laboratory Training Programs, public health students, public health workers who may participate in evaluation of public health surveillance systems, and others who are interested in this topic on reasons, steps, and attributes and uses the surveillance evaluation approach to identify gaps and facilitates discussion of practical solutions for improving a public health surveillance system.



How to use this case study    Down

General instructions: case studies in applied epidemiology allow students to practice applying epidemiologic skills in the classroom to address real-world public health problems. The case studies are used as a vital component of an applied epidemiology curriculum, rather than as stand-alone tools. They are ideally suited to reinforcing principles and skills already covered in a lecture or in background reading. This case study has a facilitator guide and a participant guide. Each facilitator should review the Facilitator Guide, gain familiarity with the outbreak and investigation on which the case study is based, review the epidemiologic principles being taught, and think of examples in the facilitator´s own experience to further illustrate the points. Ideally, participants receive the case study one part at a time during the case study session. However, if the case study is distributed in whole, participants should be asked not to look ahead.

During the case study session, one or two instructors facilitate the case study for 8 to 20 students in a classroom or conference room. The facilitator should hand out Part I and direct a participant to read one paragraph out loud, then progressing around the room and giving each participant a chance to read. Reading out loud and in turns has two advantages. First, all participants engage in the process and overcome any inhibitions by having her/his voice heard. Second, it keeps the all participants progressing through the case study at the same speed.

After a participant reads a question, the facilitator will direct participants to answer the question by perform calculations, construct graphs, or engage in a discussion of the answer. Sometimes, the facilitator can split the class to play different roles or take different sides in answering the question. As a result, participants learn from each other, not just from the facilitator. After the questions have been answered, the facilitator hands out the next part. At the end of the case study, the facilitator should direct a participant to once again read the objectives on page 1 to review and ensure that the objectives have been met.

Prerequisites: for this case study, participants should have received lectures or conducted readings in public health surveillance and public health system evaluations.

Target audience: trainees in the Uganda Field Epidemiology Training Program / Public Health Fellowship Program, other Field Epidemiology and Laboratory Training Programs (FELTPs), public health students, public health workers who may participate in evaluation of public health surveillance systems, and others who are interested in this topic.

Level of case study: advanced

Time required: Approximately 12 hours

Language: English



Case study material Up    Down



Competing interests Up    Down

The authors declare no competing interests.



Acknowledgement Up    Down

We appreciate the President´s Malaria Initiative, specifically, Dr. Mame Niang, and Dr. Kassahun Belay plus other officers from Makerere University School of Public Health and AFENET that made it possible for us to access funds for this case study development. We appreciate Phoebe Nabunya for her assistance in gathering data and other information used to develop this case study.



References Up    Down

  1. Ministry of Health Knowledge Management Portal. The Uganda Malaria Reduction Strategic Plan 2014-2020. Cited 2021 Aug 16.

  2. Talisuna AO, Noor AM, Okui AP, Snow RW. The past, present and future use of epidemiological intelligence to plan malaria vector control and parasite prevention in Uganda. Malar J. 2015 Apr 15;14:158. PubMed | Google Scholar

  3. Lukwago L, Nanyunja M, Ndayimirije N. The implementation of Integrated Disease Surveillance and Response in Uganda: a review of progress and challenges between 2001 and 2007. 2013.

  4. District Health Information System 2 (DHIS2). Open Health News [Internet]. Cited 2021 Aug 16.

  5. CDC. Updated Guidelines for Evaluating Public Health Surveillance Systems [Internet]. Cited 16 Aug 2021.

  6. ECDC. Data quality monitoring and surveillance system evaluation - A handbook of methods and applications [Internet]. Eur Cent Dis Prev Control. 2014. Cited 16 Aug 2021.

  7. Uganda Ministry of Health. Home | Mtrac [Internet]. Cited 16 Aug 2021.

  8. UNICEF. mTrac [Internet]. Cited 16 Aug 2021.