Title: Improving cholera surveillance and response: An integrated strategy from the African region

Cholera is a largely preventable disease yet it remains a leading cause of illness and death in African communities. Without functional and coordinated disease surveillance systems, national disease control programs are limited in detecting cholera in time to do something about it. In 1998, the World Health Organization's Regional Office for Africa (AFRO) adopted a strategy called Integrated Disease Surveillance and Response (IDSR) that targets priority diseases for Africa, including cholera (www.cdc.gov/idsr ). IDSR focuses on the district level, integrates surveillance with laboratory support, and uses the resulting information for public health action. We describe the IDSR framework making explicit the skills and activities critical for each surveillance function including detection, reporting, analysis, investigation, response, feedback, monitoring and evaluation. Results from recent evaluations of IDSR systems in several African countries illustrate how IDSR contributes to improvements in availability of disease information and its use in taking relevant and timely public health action. In an example from Uganda, IDSR was adopted in 2001. Indicators show improvements in timeliness of overall disease reporting and the impact on epidemic-prone diseases such as cholera. The case fatality rate for confirmed cholera decreased from 7% in 2001 when IDSR was adopted to 2% in 2007. Among the factors leading to a decrease in the cholera case fatality rate is improved response suggesting a functional disease surveillance system is a critical tool for decision-making that leads to reductions in the devastating outcomes from cholera in African communities.