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Transition from EWARN to routine surveillance

A three days workshop was conducted in Damascus, Syria from 8-10 August 2018 to disseminate findings of Early Warning Alert and Response Network (EWARN) evaluation in Syria. Participants included Ministry of Health (MOH) staff and technical EWARN officers. During this workshop the question of how and when to transition from EWARN to routine surveillance was examined.

Editorial note

The WHO Eastern Mediterranean Region (EMRO) currently has the highest proportion of countries that are experiencing humanitarian complex emergencies. As part of the Regions public health response to these emergences, WHO/EMRO is currently supporting operational EWARN systems in 7 countries (see table-2).

The question of appropriate timing and the most effective strategy for transitioning from EWARN to routine surveillance was addressed in the context of Syria during the workshop in Damascus, it is also a pertinent issue for the emergency countries with active EWARN systems. This is especially so because due to protracted humanitarian crisis, in 5 out of the 7 EWARN implementing countries in the EMR, EWARN has progressively expanded nationwide to fill the gap left by collapsing health systems, including routine surveillance. These countries include Somalia, Yemen, Syria, Iraq, Sudan and Libya.

EWARN has played a critical role in the emergency countries by ensuring early detection of outbreaks of epidemic prone diseases, and effective monitoring of outbreak response measures.

Despite its value, the guiding principles of introduction of EWARN in emergency settings should always be upheld. These include ensuring that, irrespective of scope of expansion, implementation of EWARN should always remain a temporary emergency intervention intended to address surveillance gaps when routines surveillance systems are disrupted by a man-made or natural disaster. Once emergency is over, it should not be retained longer, and the timing of exit should be linked to the return to reasonably degree of normalcy and recovery of routine public health structures and operations to a acceptable levels based on careful assessment.

EWARN as designed and implemented in emergencies is also resource intensive; it has high implementation and operating costs. This is often necessary because of the urgency, the difficult operating context, and vulnerability of target population to epidemics.
For these reasons EWARN is neither appropriate nor sustainable for use as a routine surveillance system once emergency is over. Furthermore an effective exit strategy should (see table-1) ensure a gradual integration of the EWARN to the routine surveillance system after the end of an emergency, through retention and adoption of best practices of EWARN .