AVADAR

The Importance of High-Quality AFP Surveillance Data in the Fight to Eradicate Polio

Polio is targeted for eradication because the presence of the virus anywhere means that children everywhere are at risk. The Global Polio Eradication Initiative (GPEI) focuses on strengthening Acute Flaccid Paralysis (AFP) surveillance worldwide to detect and respond to the poliovirus, to build herd immunity to protect the population and to halt the transmission of the virus. The data on the spread of AFP is invaluable especially for polio-endemic countries like Afghanistan, Pakistan, and Nigeria because it helps in determining whether they can finally be certified polio-free.

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There are four steps involved in AFP surveillance and the Auto- Visual AFP Detection and Reporting (AVADAR) project responds to the first step—finding and reporting children with AFP—in eight priority countries in Africa. In many of these countries, disease surveillance and notification officers (DSNOs) at the health facilities are unable to actively find AFP cases for reasons ranging from difficulty in accessing settlements to security challenges. AVADAR trains community informants to search for and report the presence and/or absence of children with AFP in their community, using a mobile application. The application also has an embedded video that shows a child with AFP so that community informants can better recognize an AFP case. This reduces the burden on the DSNOs and allows them to focus on confirming if the case is truly AFP or not.

How AVADAR works

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To ensure that AFP surveillance is conducted impactfully and that the AFP surveillance data collected is accurate, timely and of high quality, the GPEI defined five global indicators: Completeness of reporting, Completeness of case investigation, Completeness of follow-up, Sensitivity of surveillance and Laboratory performance.

Global Polio Eradication Initiative: AFP Surveillance indicators

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AVADAR was designed by eHealth Africa, Novel-T, the World Health Organization (WHO) and other partners, to contribute to the achievement of the above targets. Below are the measures that have been put in place to ensure the collection and use of high-quality data to track and reports suspected AFP cases, and to inform decision making for polio eradication.

  • Coverage: To decide where to site an AVADAR system, WHO carries out an assessment of the target country/districts to identify rural, hard-to-reach and underserved communities which are typically more predisposed to poliomyelitis. The AVADAR system, equipped with geospatial tracking capabilities is then deployed to community informants/ AFP reporters. This unique feature of the application helps to validate the location of the suspected AFP case, independent of the reporter.  

  • Reporting: The AVADAR application allows informants to deliver reports anywhere and anytime in order to prevent data loss and to ensure near real-time, accurate reporting.  The app is designed to be used by people with basic literacy levels and is available in eighteen local African languages for ease of understanding. A report is better able to provide insight and enhance planning or decision making when it is timely. One of the key weekly metrics captured on the AVADAR dashboard is the number of complete results that were submitted as at when due, thus ensuring that all informants are actively engaged. Informants are expected to look out for and report cases of children aged 15 years and below, who have any form of physical deformity on the limbs or arms. In the event that no AFP case has been sighted within a week, the informant must send a ‘no report’, to validate his presence on the system.  

    AVADAR has improved the rate of AFP reporting compared to the traditional system of AFP reporting. For example, between June 2017 and June 2018 in the Lake Chad Basin countries(Chad, Niger, Nigeria, and Cameroon), the AVADAR system recorded 589 supsected cases against the 213 cases recorded by the traditional AFP Surveillance system.

  • Verification: Paralysis in children can be caused by several agents including the Poliovirus. After the community informants submit their reports of suspected AFP cases, trained health workers carry out further investigations to confirm if they are true AFP cases. The WHO has designated laboratories all over target countries that are certified to test fecal samples and isolate the poliovirus. AVADAR weekly reports show how many suspected AFP cases were reported, how many were tested and the number of cases confirmed to be true AFP cases. This sort of data measures the cost of a single confirmed AFP case, the prevalence and incidence of AFP in target areas, thus enhancing the quality of AFP surveillance data for decision making.

AVADAR dashboard

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Having data on the spread of AFP in a geographic location helps with planning towards its containment. Since Poliomyelitis is mainly oral-fecally transmitted, sanitization and sensitization of the environment and inhabitants respectively can help reduce the spread of polio.  AFP data gathered across different locations has been used in making an informed decision on determining the number of health workers that can effectively manage its spread to neighboring communities. On the contrary, no data or false data could lead to health workers focusing their energy in wrong locations thereby risking the spread of polio and the extension of its existence.

Without reliable and accurate AFP surveillance data, true progress towards polio eradication cannot be measured. AVADAR’s impact in high-risk countries across Africa demonstrates how context-appropriate interventions and solutions can transform disease surveillance and emergency management systems.

One of the most important features of the AVADAR system is the engagement of over a hundred community informants per county. They are trained and equipped for the first time to provide timely reports that can be accessed at all levels from the county to the national level and beyond, thereby allowing suspected cases to be investigated in an accurate and efficient way.
— Dr Sylvester Maleghemi, WHO Polio Eradication Initiative Team Lead, South Sudan

International Translation Day Spotlight: AVADAR

By Adaeze Obiako

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If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.
— Nelson Mandela

This year, the United Nations is celebrating “International Translation Day” for the first time. The celebration is an opportunity to pay tribute to language professionals, whose work plays an important role in bringing nations together, facilitating dialogue, fostering understanding and cooperation, and contributing to the development and strengthening of world peace and security.

For eHealth Africa (eHA), translation has been instrumental to the success of several projects, particularly the Auto-Visual AFP Detection and Reporting (AVADAR) project.

When AVADAR commenced in 2016, we knew it was a worthwhile intervention towards the eradication of polio in Nigeria; however, we could not have anticipated just how much of a positive impact it would end up having on the Acute Flaccid Paralysis (AFP) surveillance system across Africa. Between 2016 and 2018, AVADAR grew from a small pilot in two states in Nigeria to a full-fledged project across 8 West and Central African nations. Several factors contributed to the success and scale of the project, one of which was the educational AFP video embedded in the AVADAR mobile app used to train community informants on proper detection (and subsequent reporting to health authorities) of AFP cases within their communities.

This is where language came in.

The project management team, made up of the World Health Organization (WHO), country Ministries of Health, the Bill and Melinda Gates Foundation, Novel-T, and eHA, knew early on that the key to ensuring accurate AFP detection and proper use of the AVADAR app for case reporting lay with developing a sense of connectedness and trust between all stakeholders (from project implementers to health workers to community informants) through the breakdown of language barriers.

Part of the pre-implementation phase in each country included research into what languages were spoken by indigenes using the AVADAR app and the AFP video, and the entire app was translated into each applicable language. Below is an example of the AFP video translated into Hausa, a local language commonly spoken in northern Nigeria, Niger, Chad, Cameroon and the Central African Republic.

In addition to the AFP video and app being translated into multiple languages, the training facilitators (who train informants on how to use the app) and field officers (who provide weekly phone troubleshooting support to informants) were all indigenes of the implementing regions and fluent in the local languages to ensure ease of communication and understanding for the AVADAR informants.

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As AVADAR continues operation across Africa, it is clear that we have the power of translation to thank for bridging the gap and allowing thousands of community members and health workers across different African nations to support the fight against polio. At this rate, it won't be too long before polio, like smallpox, is considered a public health issue of the "past".






eHealth Africa Pilots AVADAR Surveillance System to Track Progress Toward Polio Eradication

By Daniel Ojabo

In response to the recently reported cases of wild poliovirus in Nigeria, eHealth Africa (eHA) partnered with Bill and Melinda Gates Foundation, WHO, and Novel-T to pilot a mobile-based surveillance application  for Acute Flaccid Paralysis (AFP) in children.

Defined by WHO as “a rapid onset of weakness of an individual's extremities”, AFP often causes weakness of the muscles of respiration and swallowing, progressing to maximum severity within 1-10 days. AFP surveillance, being one of the four cornerstone strategies of polio eradication, seeks to identify all cases of polio through a system that targets any case of AFP as a potential case of polio. The surveillance tool is an Auto-Visual AFP Detection and Reporting (AVADAR) mobile application installed on android-enabled mobile devices, provided to Health Workers and Community Informants, to aid in the detection and reporting of AFP cases within health facilities and local communities.

Screenshots of AVADAR Application

Screenshots of AVADAR Application

According to the project manager, Umar K. Idris, “AVADAR was designed to improve the sensitivity and quality of AFP surveillance, particularly in places with low performance indicators”.

The AVADAR project was piloted on 5 August, 2016 in the Local Government Areas (LGAs) of Oyun (Kwara state) and Kuje (FCT, Abuja) for an 8 week period. In Kuje, community informants reported 26 AFP cases within the 8 week period. This was a considerable increase compared to only 23 cases reported in the 33 week period (from January to July 2016) before implementation of the AVADAR pilot. Similarly, in Oyun there were 8 reported AFP cases within the 8 week period (August to October 2016), compared to only 4 reported cases in the 33 week period prior to AVADAR.

Building on the successes achieved, the project was scaled up to include 8 LGAs in Borno state in November 2016, with plans to further expand into other states.

“We are on the verge of expanding into Adamawa, Sokoto and Yobe. We also aim to implement it in the Lake Chad Region (Chad, Cameroon & Niger Republic), post-Ebola countries (Guinea, Liberia, Sierra Leone), as well as the Democratic Republic of Congo and South Sudan in 2017”, Idris said.

According to the Global Polio Eradication Initiative (GPEI), the absence of AFP surveillance provides a gateway for wild poliovirus to continue circulating around the world. Innovations like AVADAR have already  improved the surveillance network by providing health workers and community informants with an active surveillance tool to effectively report suspected AFP cases. The surveillance data will serve as a measure of progress towards polio eradication and allow polio program stakeholders to effectively plan and implement strategies for supplementary immunization activities (e.g. national immunization campaigns).

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To strengthen communication amongst the local health workers and community informants, eHA trained over 800 health workers and provided them with over 800 GPS-enabled smartphones and solar chargers.AVADAR has expanded the surveillance network by bringing in more community informants, health workers and designated health facilities to improve the sensitivity of AFP surveillance amongst surveillance personnel (in terms of timely detection and reporting). The AVADAR software includes an embedded 30-second video of a live child with AFP symptoms having difficulty crawling/walking, as well as an electronic data collection form for submission of detailed information on suspected AFP case patients. This video is sent as a weekly reminder to Health Workers and Community Informants (on their GPS-enabled mobile phones) responsible for reporting all suspected AFP cases in their health facilities and communities.