Abstract

Measles is a leading cause of death among children under five years world-wide. In Afghanistan, measles claimed 35,000 lives in 2001. Despite reported measles vaccination coverage of 75%, the number of outbreaks was increasing in 2008. The systems involved in measles surveillance in Afghanistan include: Health Management Information System (HMIS), Disease Early Warning System (DEWS), and the Expanded Program on Immunization (EPI). These three systems were evaluated to identify their strengths and weaknesses and formulate recommendations. A qualitative study based on the CDC updated guidelines for evaluating public health surveillance systems was conducted. A detailed checklist was developed and used during the interview with the candidates to collect information about the system attributes. Data were collected from representatives of all mapped stakeholders through face-to-face interviews, telephone, and email. System attributes were assessed and scored for description and comparison on a Likert scale from 1 to 10. The average of scores was obtained to determine the overall ranking.  World Health Organization (WHO) estimates for measles cases in the county (2008) was used to calculate sensitivity and predictive values. HMIS scored well for acceptability, cost effectiveness, representativeness, but had poor timeliness and flexibility. The sensitivity of EPI, HIMS and DEWS were 40, 34 and 20%, respectively and predictive value positive (PVP) of the system EPI, HMIS, DEWS were 69, 61 and 22%, respectively. EPI scored well for data quality, representativeness, and stability, but poorly in flexibility, timeliness and cost effectiveness. DEWS had good data quality, timeliness and flexibility, but weak stability. None of the systems has up to the mark attributes, and none of these systems can provide all necessary information to the health system alone. Systems are fragmented and serve different objectives. Lack of integration limits utilization of generated data for policy and planning. Measles surveillance through EPI should be strengthened and integrated with DEWS and HMIS to enhance cases detection and timely response.

Key words: Measles, measles surveillance evaluation, surveillance system, Afghanistan.