Preliminary Evaluation On The Feasibility Of The Comprehensive Vector Surveillance System In China

Preliminary Evaluation on the Feasibility of the Comprehensive Vector Surveillance System in ChinaMPH candidate:Liu QiyongAdviser:Yang WeizhongChinese Center for Disease Control and PreventionIntroductionVector surveillance is a fundamental process in vector borne disease(VBD) control and prevention.In China we have done some vector surveillance programs in the past. But the methods varied with different areas,so it is hard to do data comparison and analysis.And the intensity of some VBDs and the areas prone to them has changed a lot along with economic globalization,urbanization and global climate change,etc. Simultaneously,some emerging VBDs become public health problem and the other VBDs pose high risk to enter into China from abroad.So it is essential to emend the surveillance system to make it more feasible and effective.Now a new well-planned comprehensive vector surveillance and alert system is necessary and is establishing in 2005.Forty surveillance scenarios are chosen and distributed in seventeen provinces(see figure below) for testing.It is just a testing program and it needs assessing and emending for the enlargement of the program in 2006 in all over China. BackgroundVBDs are still rampant throughout the world although medical technology is developing quickly.VBDs contribute about 5%to the total morbidity,and nearly 30% to the total mortality in China.And vectors may play a role in the transmission of non-VBDs.So it is necessary to detect the vector density trend for alert and response to VBDs.Moreover,it is essential to understand the factors that caused increased vector density and hence the transmission of disease to prevent the emergence and resurgence of more diseases,as well as to serve as a basis for effective control(Gratz, 1999).The government of China has carried out a patriotic health campaign named 'elimination of four pests' for disease control since 1950's because the Four-Pests, such as rodents,mosquitoes,flies and cockroaches,are usually important disease vectors.From 1985 to 1988,a national surveillance system was developed for monitoring the Four-Pests.It did play a role in disease control and improving human's environment.However,the methodology was not emended along with the alteration of VBDs and the program management didn't adapt to the socioeconomic circumstances.As a result,the late data could not reflect the fact.At last,the system lost its original function on surveillance and alert to VBDs outbreak.Here are some examples.The plague emerged around TianSheng Bridge Reservoir from 2000 to 2003 without any alert.Thousands of patients were infected with dengue fever in Guangzhou 2002.Moreover,the outbreak of SARS led to a huge economic loss and social turbulence.All the above brought more demands to the surveillance system. Summarizing the original system,we can find that it needs rethinking and emending in the following points.First,the original methods were not timely regulated with the variation of VBDs and related factors.Second,the former system didn't emphasize the relationship between vectors and diseases.Third,the management was not smooth and scientific in some way.Fourth,the fund was not enough or used sufficiently. Now we have started establishing a new comprehensive vector surveillance system different from the Four-Pests Surveillance System,and we have chosen 40 cities from 17 provinces for testing.China CDC is responsible for drafting,emending and perfecting the surveillance program,and holding surveillance technique guidance and training.The program needs assessing and emending for the enlargement in 2006 in all over China.The firs priority should be placed on the preliminary evaluation on the feasibility of the Comprehensive Vector Surveillance System in China for its sustainability and wellbeing.Aim of the ProjectThis project aims to assess the feasibility of the comprehensive vector surveillance system for emending it.This research will review and analyze the structure,dynamics and management, strength and weakness of the comprehensive vector surveillance system in 17 provinces,as well as get a clear understanding of how the program contributes science basis for responding VBDs outbreak and infestation in local and national level.Research QuestionThe overall research question is "how is the feasibility of the comprehensive vector surveillance system for China"Objectives and Focus QuestionObjective 1:to evaluate the feasibility of the comprehensive vector surveillance system in 17 provinces with focus on the practiceFocus question 1:what are the characters of physical setting and practical conditions of the target provinces?Focus question 2:what are the personnel structure,dynamics and management of the program in these areas?Focus question 3:what are strengths and weakness of the new system?Objective 2:to provide recommendations for emending the new system Focus question 1:what are the remaining problems and challenges in vector surveillance?Focus question 2:what are the recommendations for emending the items of the system?SignificanceThe project will evaluate the feasibility of the new vector surveillance system for emending it and developing a more comprehensive vector surveillance system.It is the first assessment on the program and will offer scientific basis to decision making for the well circulating of the system.This seems urgent and necessary for the enlargement of the program in 2006 all over China.MethodologySurvey is a common technique,and has been with us for a long time.In the seventeenth century,the skill has been noted for assessing the effects of the plague in London.Today,it is applied widely,especially in the social research.Bryman(1989) defined survey like this "survey research entails the collection of data on a number of data on a number of units and usually at a single juncture in time,with a view to collecting systematically a body of quantifiable data in respect of a number of variables which are then examined to discern patterns of association".(Conlin,2002)Survey can be done by many ways.Mail,telephone,and interview are usual designed methods(Reviere,et.al.1996).For all survey,the first disadvantage is the attitude of informant can affect the data which been gathered,the second is respondents always refuse to show the real perspective about their beliefs,characteristic etc.when these questions are sensitive for them.The data collected is not complete for these reasons. But survey can provide simple and straightforward approach to understand the respondents' values,motives and attitudes,and it is easy for gathering standard information from almost all human population,and the high amounts of data is convention for analyzing(Robson,2002).In this study,the multi-survey can be used involving mail survey and interview survey. There are seventeen provinces have been involved in the new comprehensive vector surveillance system.It is divided into five parts:eastern,western,southern,northern and central China.Each part consists of several pilot provinces,each with several cities' health sectors.In every pilot province or city,there are administers and professional workers work for the vector surveillance.The questionnaires were mailed to the pilot provinces which were chosen for evaluating according to spatial distribution.So,seven provinces with 16 institutions were chosen for the evaluation project.The questionnaires were designed into several types varied with province to city.In the province or city level,the informants could class two groups:administers and professional workers.Different group should answer the specific questionnaire. The scenario areas for interview survey were chosen depending on the specific reasons.The representative points investigated were chosen from the five parts and each part should include at least one province and one city. QuestionnairesThe questionnaire enquired five portions as follows:a) organizations and institution,it aims to clarify if the organization framework is reasonable and fit for a well-operation of this surveillance in the past and current,and the status of the employee in the system include training,b) finance for surveillance system,the intention is to know the source or usage of finance supporting for the system,c) the history of surveillance system,to understand the past surveillance system,d) the status of surveillance system,to reflect the facility and other factors,e) the outcome of surveillance,the quality of the system operating will be known based on it.Except this,another questionnaire has been designed to detect the information of professional working for the vector monitoring system.(Please refer to Appendix 1)Supplementary field interviews Observation is a basic method applied in a real world research.It is a social science research method and widely used in many research projects.The researchers are required to use all the sense of them including eye,ear to collect the needed information.Generally,there are four types for the researcher attending:complete observer,observer as participant,and participant as observer and complete participant. The researchers choose the needed method through the purpose and goal of the ongoing project(Cordia,2004).The major advantage of observation is you can get the information directly just watching and listening what they do and what they say,and not to asking their perspective just by feeling.Observation also is a real method can get 'real life' in a real world.But sometimes,because of the interrupting of observation,the response cannot show the real aspect,the result is not real. Observation is a time-consuming method.For getting the true data and for comparing, you should go to several unions for observing,it demands a long time to do(Robson, 2002).In this study,two or three people were chosen as a small group to investigate the pilot provinces and cities in each part(there are five parts mentioned as above).The mission included knowing the situation of the system operating,the training of professionals,the using of the finance,and the surveillance work of worker via checking the documents.The observation spots were clarified exactitude or not which selected for monitoring mosquitoes,rodents,cockroaches and flies according to the protocol for surveillance system.It needed to confirm the reliability of the data by examining the form,monthly and yearly.The information of facilities equipped was collected for judging if they are sufficient.The professionals were tested to know if they master the knowledge of vector-borne disease and if they control the method of monitoring vectors.By collecting the information from representational provinces or cities it will be known the basic condition of the surveillance system in China,and the dependable approach will be adopted to solve potential problems. Focus groupFocus group is a useful technique for this project.As a special interview method, focus group is an open-ended group discussion guided by usually six or twelve people; it is a time-assuming interview,always extending over at least an hour,possibly two or more.There is discussion about whether the groups should be homogeneous or heterogeneous.Homogeneous groups ask for the group members own the similar property:such as gender,age,occupation,and education.Homogeneous groups can promote communication easier;facilitate an exchange of ideas and experiences,and may get a result as groupthink.Heterogeneous groups come from different background,position or experience,it can encourage and enrich the discussion, stimulate other group members with different view to look at the topic,and may risk power imbalance.In our study,the group is homogeneous(Robson,2002).Focus group is a efficient technique for collecting qualitative data from several people at the same time,and the most important topic easy to be focused on in the helping of group dynamics,and the method is not expensive and it is flexible can be provided quickly,group participant also are empowered and express their views in their world, can enrich the range and amount of data.But focus group is always time-consuming, the number of questions covered is limited in a short time;the good organizer is needed to manage the interview process,and conflicts may usually arise between personalities(Robson,2002).In this study,we invited the participants intended the focus group.In the representative provinces or cities,the number of people works for vector surveillance system is short of twelve;a focus group is set up in some areas.Every participant should discuss the shortage of the system,put forward the suggestion about it,show the difficulty of them in finance and facility,and state their reason,provide the advice for solving it,etc.The style of it adopt structure or semi-structure,manager as recorder,noted the question and the answer which the group discussing,each meeting is not over three hours for avoiding people is boring.The expert is acted as manager for ensuring the quality.Focus group discussion can get various meaning together,expand the range and scope of this system,collect different data from different people,and help the manager take some measure to eliminate the potentials effect to the system,inspire the system become consummate.Ethical IssuesEthics is a necessary role for social research.Ethics are usually taken referring to general principles of what one ought to do when both are concerned with what is good or bad,right or wrong(Robson,2002).In this project,some ethics should be provided for promoting the process of this research,and get the real information from respondents.A major ethical issue in survey research is the invasion of privacy.When the questionnaire was designed,some private question was avoided,and respondents have a right to decide whether or not to reveal their personal information.To some necessary question should be known,setting a safe circumstance for them.So they believe the answer will remain confidential,and the answers will be serious and legitimate(Neuman,2003).Another ethical issue is anonymity.For protecting the right of respondents and ensuring the answers' quality,the questionnaire paper will be anonymous.The recorders in the focus meeting only record the answer of question put forward,unless permitting,we do not note his or her name. As such,confidentiality is very important in this research.The data and result of this research will be kept secretly.The data include morbidity,mortality,the distribution situation of vector-borne disease,the density of vector,the amount and source of finance,the name of respondents,ect.All the documents of this study are conducted by personal specially,and the data will be stored in particular place.No admitting,the person except administrator and executants will not consult these data(Neuman,2003).Research RigourHow to control the quality of this research and get the reliable result? It is a process through out the research,from the starting of it to the ending,including design of it and the operation of the data.A completely process design can almost assure the real outcome.1.The design of the study:in the step of design,invited the experts from different fields including VBDs experts,epidemiologist,statistician to study the feasibility, validity and availability of this protocol,revise the shortage of it,and confirm the design.2.The design of questionnaire:review literature,design the first draft of it,then do a rapid appraisal(RA)(Cordia,2004) to gain the basic data.According to the result of this pilot test,revise the weakness,and then do RA again.Several reflective cyclic processes have been done;the questionnaire almost can be decided.Finally,relevant experts were invited to evaluate the paper and do the final revising,then finish the questionnaire paper.3.Questionnaire paper:the paper is with good quality and easy to be viewed,the time for filling in this paper is enough for respondents.Before the respondents answering this paper,it needs to declare that they should answer the questionnaire by themselves, and every question should not be omitted.If necessary,we can help them to answer some questions,which they are not willing to do.When all of the people finish their form,the papers were taken back on the spot.4.Focus group:the discussion was presided by the researcher of this study,the method was adopted structure and semi-structure,the outline of the question was ready aforehand.After the meeting,the answers were conducted in time.5.Data operation:the qualitative and quantitative data collected by various methods were input in computer with the same format.Before type in,they were examined carefully.At the same time,the data were verified error using logical verify method.Results and analysisThe feasibility indicators with focus on practice:(1) Construction of organization and management for the project activities How about the integrating?According to the results of questionnaires(please refer to appendix2),the project was organized well in different provinces.In every investigated province,the project was managed and organized as a program of the local Centre for Disease Control and prevention.Of 15 investigated institutes,14 institutes initiated the projects with a conference,and the protocol was discussed in the conference in order to make all participators master the methods of surveillance.4 institutes got additional financial supports from local government besides the support from national CDC.During the proceeding of the project,13 institutes sent out experts to the surveillance sites to check the development of the projects and gave technical supports to the surveillance staff.For most of institutes,the surveillance was carried out based on an academic department of vector biology and control,which insures that the project was carried out with enough scientific supports.Most chiefs(14) of the departments were senior staffs with academic experiences more than 20 years.Most of these chiefs have the background of preventive medicine or related areas.The training of staffs is of important for the development of the surveillances.(2) Implementation and sustainabilityHow about the practice accordance with the protocols?According to the results of questionnaires,almost all investigated institutes(14 of 15) began the surveillances at August although there were some difficulties,such as finance,human power and equipments.Before the beginning of the surveillance,most of the institutes(14 of 15) organized training courses for the surveillance methods, basic knowledge of vectors and the usage of equipments.More than 400 people took part in the training courses organized by seven provincial centers of Disease Control and Prevention of 6 provinces.While according to the some results of surveillance, there are some problems in the training,for example,somebody did not know how to measure the body length of rodents,and somebody met difficulties to identify specimens of mosquitoes.That suggests that a systematic training is necessary for the sustainability of the surveillance system.(3) Financial indicators for the programFinancial component for the program in different level,what is the obstacle?To support the working of all surveillance sites,Chinese Center for Disease Control and Prevention allocates funds to every site Y 20,000 RMB as the subsidiary.The national CDC hoped that the local governments and health department in different levels can give other financial support to the surveillance system,and the more important,that the government can support the surveillance system in regular financial budget.According to the questionnaires,in the first year of surveillance, only 4 institutes got additional financial support from local government and other sources in this year.The reason for the lack of financial support in some institutes should be that the plan of surveillance was initiated later after the annual budget of the provincial governments.While the additional support was more important than the support from China CDC,it is necessary that the local government of the surveillance sites give enough financial supports in the following years to ensure the sustainability of surveillance system.(4) Personnel indicators for the programIn most of the pilot provinces,the surveillance was carried out by a group of staffs with sufficient training and experiences of related works.These staffs were organized and specialized for the surveillance of different vector,data analysis and data reporting.Among the 16 investigated institutes,13 of them designated special staffs for surveillance of special vector.And almost all institutes appointed staffs for data analysis and data reporting.All these efforts ensure the operating of the surveillance system.Besides the professional staffs,people from communities and some PCO (Pest Control Operation) companies were also organized and trained to take part in the surveillance to overcome the short of human power in the field work.Most of these people took part in surveillance regularly so that they had enough knowledge and experiences of the surveillance,and also make the surveillance system work fluently. In conclusion,the knowledge and technique capacity are generally satisfactory for the performance of the program.(5) Accessibility to the equipments for the programAll institutes carrying out the surveillance had necessary equipments.That means the accessibility of the equipments is not a problem at all.But several institutes complained the quality of the equipments,such as the glue board used to catch roach. It suggests that some equipment does not meet the requirement of surveillances.It is necessary to give a list of high quality equipments fit for the surveillance of vectors instead of collection of vectors.(6) Perspectives about the strength of the new program The new comprehensive vector surveillance system is an open-end program for the disease vectors of public health importance compared to the Four-Pests surveillance. The protocol for the vector surveillance system offers a standard national technical guideline not only for vector surveillance and control against vector borne diseases, but also for pest surveillance and control.It will benefit the data sharing and information sharing within local,national and international level.The updating data and information from the program is able to provide scientific basis to policy making on strategy and technique for sustainable vector management.This is more helpful to emergency responding.(7) Perspectives about the weakness of the new programAs the first year of the surveillance,it was acceptable that there were some weakness of the program.According to the results of questionnaires,some methods of surveillance were dependent on the experiences of operators.Two methods were regarded as dependent methods including the surveillance method of rodents with trap-night method,and the surveillance method of mosquitoes with person-hour method.When the protocol was written,it was clear that some methods were not perfect for the surveillance.We are seeking a better method for mosquito surveillance based on UV light trap of which the results are more objective than the method used.(8) Workload of the new programThe suitable workload of the program could affect the quality of the results.In any case,the sample amounts should be real and representative.Hence,the protocol stipulates the least workload.However,most of the participators complained it was too heavy.It may reflect the shortage of human power for vector surveillance and control.On the other hand,the skill and proficiency needs be improved.(9) Satisfaction or complains of professionals to do the surveillance All people regarded the surveillance system as a great development for the control of vectors and related diseases.The regulative surveillance would not only give important information for the vector control,but also stimulate the development of department of vector control in different level of Center for Disease Control and Prevention in China.Because of the ignoring of the important role of the vectors in the transmission of disease in several years,the teams of vector biology and control in different level of CDC of China were not stable and the related equipments were not updated regularly.The initiation of the vector surveillance program gave the professional the opportunities of series of systematic trainings for vector biology and control,and financial support for updating of necessary equipments for daily work. But most people complained that the financial support were so limit that can not meet the need of surveillances.Another problem is the bait for fly.The recommended bait is composed of sugar and vinegar,which is effective for houseflies(Musca domestica),but does not work well for others species of flies around food markets and small restaurants.Good bait for the surveillance of fly is then necessary.The knowledge and possession of technique of the participants are satisfied for the performance of the program.Conclusions and recommendationsThe feasibility of the comprehensive vector surveillance system with focus on practiceThe new comprehensive vector surveillance system is generally satisfied and sustainable within the pilot provinces.The organization framework was established and worked well.The financial support could almost burden the operation of the system.The technical protocol has scientific basis,reasonable and could be understand and implemented.Most participants were trained and could follow the guidelines.The results of the surveillance are reliable and useful.The recommendations for emending the comprehensive vector surveillance system The new comprehensive vector surveillance system should be consolidated in the next years within the pilot provinces.The new pilot provinces need carefully assessing on the basis for implementing the national program with focus on the physical setting, human power,and financial support.A regular training network for the system is recommended to establish and the taxology of disease vectors needs be emphasized.The local financial support should be integrated to the annual budget for public health of the government and be specified for vector surveillance and control. For a better sharing of the data and information,a reporting system will be designed and used smoothly with internet techniques.Although,the protocol for the vector surveillance system offers a standard national technical guideline,a seminar is urgent to hold for emending some items of the technical protocols before the next annual operation.For instance,good bait for the surveillance of fly is necessary especially for the species of flies except housefly around food markets and small restaurants.The mosquito trapping equipment is also a tough problem.Finally,the evaluating methodology is reliable and some specific items need modified and refined.