Evaluation of Surveillance and Response System of Healthcare-Associated Infections and Outbreaks, Regional Level, Saudi Arabia, 2019

Background: HAI is a disease occurred due to healthcare and is associated with a great deal of morbidity, mortality, and increased financial burden. Objective: To assess the capacity of surveillance and response systems of HAIs and HAIOs in regions in Saudi Arabia. Methodology: A cross-sectional study was conducted at the regional level in Saudi Arabia. The WHO model for surveillance questionnaire was modified and filled from the regional level. Results: 78.57 % of regions had surveillance manuals. Only 24.4 % of reports were sent. 54.54 % of the outbreaks were reported, and 63.64 % were investigated. Half of the regions did not have a budget or funds. Half of the areas had a shortage in the staff. The main level visited only 35.7 % of the regions. Conclusion: The surveillance system at the regional level needs improvement in its core and support functions.


Hypothesis:
The surveillance and response systems of HAIs and HAIOs in the regions are not effective, not sensitive, inconsistent, and not timely systems.

Goal:
To have robust and standardized surveillance and response systems of HAIs and HAIOs in the regions.

Objectives:
General objective: To assess the capacity of surveillance and response systems of HAIs and HAIOs, in the regions, in Saudi Arabia.

Specific objectives:
➢ To employ standardized assessment tools to obtain information about the capabilities (in terms of core and support functions) of surveillance and response systems of HAIs and HAIOs at the regional level.
➢ Identify weaknesses (absence of core and support functions) in the regions' surveillance and response systems of HAIs and HAIOs.
➢ To develop an action plan to strengthen the capacity of surveillance and response systems of HAIs and HAIOs at the regional level based on the assessment findings.

Methodology:
Study design: A cross-sectional study.
Study population: Infection control coordinators in health directorates in Saudi Arabia.

Sample calculation:
The study covered all populations after applying inclusion and exclusion criteria.
No statistical tests were needed to calculate sample size (n) because of the small number available.

Inclusion Criteria:
The questionnaire was filled out by someone who has worked for at least a year and above. Language, gender, and nationality were not barriers in the study.
Exclusion Criteria: Anyone working for less than a year was omitted because he may not have received formal training.

Data collection:
Self-administered questionnaires were the techniques to collect data.
The principal investigator explained the questions to the participants when needed via a telephone call. The questionnaires were administered in English by email to the coordinators. These tools are based on the Protocol for the Assessment of National Communicable Disease Surveillance and Response Systems, which was developed for WHO. The protocol was recommended by whom to help the national teams in their evaluation of surveillance and response systems for communicable diseases, including HAIs. [11] The WHO designed three levels of generic questionnaires: central, district (intermediate), and health facility (service). This study used only a regional-level questionnaire-the WHO-designed The research comprised a regional infection control directorate.

Analysis plan:
A simple calculator was used because it was a descriptive analysis.
The data was analyzed to respond to the objectives of the study.
Frequency of different explanatory variables, such as the availability forms, priority list of HAIs and standard case definition, etc. was estimated to know their percentages to find out the gaps and the opportunities in our surveillance and response systems of HAIs and HAIOs.
The investigator concentrated on both HAIs and HAIOs. The answer options were "present" and "absent."

Ethical concerns:
1-No ethical approval was taken because the study was to evaluate the system with minimal risk to participants.
2-The verbal consent was taken from health authorities and the participants after a summary of the study. 5-Participants' anonymity and autonomy were respected, and the principal investigator only was responsible for the content, and the participants were not included in the report. 6-The purpose of collecting information is to improve the surveillance of HAIs through scientific recommendations.

Budget:
No budget from MOH or any institution because they have complicated procedures and difficulty giving support. No other external fund. The study is self-funding.

Identifiers:
Among 20 health directorates, 14 have completed the questionnaire and submitted it through email, with a response rate of 70 %. Six (30 %) health directorates did not finish till the moment of writing the result despite continuous contact by the principal investigator.
Indicator; availability of national surveillance manual: 11 health directorates (78.57 %) said that there is a national manual for surveillance and response systems of single HAIs, while two (14.29 %) said "no" and one (7.14 %) did not know.
10 health directorates (71.43 %) said that there is a national manual for surveillance and response systems of HAIOs, while 1 (21.43 %) said "no" and one (7.14 %) did not know.

Case confirmation indicator:
13 health directorates (92.86 %) reported that there is a capacity to transport specimens to a higher level laboratory, while 1 (7.14 %) said "no." 12 health directorates (85.71 %) reported that there are guidelines for specimen collection, handling, and transportation to the next level, while two (14.29 %) said "no."

Registration indicator:
Thirteen health directorates (92.86 %) admitted that there is a surveillance register for single HAIs, while one (7.14 %) admitted "no." Six health directorates (42.86 %) participants acknowledged that the type of register is electronic only, and the same percent admitted the presence of both manual and electronic, but one (7.14 %) admitted that there are manual registers only. 11 health directorates (78.57 %) admitted that there is a surveillance register for HAIOs. Four coordinators (28.57 %) revealed that the register type is electronic only, and the same admitted that the only manual record is available. There are manual and electronic registers in three regions (21.43 %).
10 coordinators (71.43 %) mentioned that they checked the logbook daily, while one (7.14 %) cited "no," aand three (21.43 %) said sometimes. (Table 1)   ***Response is for number of reports while frequency is for number of regions and calculation is from region sent reports.
* Presence of deficiency of forms means not available. **One region said that there is also weekly reporting. One region said that, reporting for HAIOs is within 24 hours and there is a monthly reporting for surveillance. Three regions admitted that no monthly report. Data is unavailable in four regions.

Data analysis indicator:
12 regions (85.71 %) reported that there is an analysis of HAIs and HAIOs data by the person (gender and age), but two areas (14.29 %) said "no." 13 regions (92.86 %) reported that there is an analysis of HAIs and HAIOs data by time and place, but one part (7.14 %) said "no." 10 regions (71.43 %) reported that there is an analysis of HAIs and HAIOs data by causes, but three areas (21.43 %) said "no." One region (7.14 %) said only partial analysis of causes.
Eight regions (57.14 %) reported that there is an analysis of HAIs and HAIOs data by vehicles, but five areas (35.71 %) said "no." One coordinator (7.14 %) does not know.
Nine regions (64.29 %) reported that there is an analysis of HAIs and HAIOs data by contributing factors, but four areas (28.57 %) said "no." One province (7.14 %) said only partial analysis of contributing factors.
12 regions (85.71 %) reported that there is an analysis of HAIs and HAIOs data by trends, but two areas (14.29 %) said "no."

HAIR investigation indicator:
Nine directorates (64.29 %) reported 11 HAIOs in the last year. Six 12 directorates (85.71 %) mentioned that there is a standard case management protocol for HAIOs, while one (7.14 %) said "no" and one (7.14 %) did not know. 13 coordinators (92.86 %) mentioned that they know all regional stakeholders.
11 coordinators (78.57 %) mentioned that the stakeholders implement preventive and control measures, while two (14.29 %) said "no" and one (7.14 %) did not know.
Eight coordinators (57.14 %) mentioned that the stakeholders did hold meetings the past year to evaluate their outbreak preparedness, while five (35.71%) said "no," and one (7.14 %) did not know. (Table 3)

Resources indicator:
For data management resources in the regional infection control For transportation, the department has a car, as reported by eight (57.14 %) coordinators, while four (28.57 %) coordinators said "no," and one (7.14 %) coordinator does not know.
The staff is enough to cover the program duties, as reported by 5 (35.71 %) coordinators, while not enough, as written by seven (50 %) and one (7.14 %) coordinator does not know.

Cooperation and coordination indicator:
12 regions (85.71 %) admitted that there is surveillance cooperation and coordination body at the regional level, while one (7.14 %) admitted "no." Seven regions (50 %) were satisfied with the surveillance system, while seven (28.57 %) were not, and one (7.14 %) said does not know. The study targeted the regional level, consisting of 20 health regions.

Discussion
The data were collected through email only, so the observation part of the evaluation is unavailable, negatively affecting the evaluation process. Representativeness of the surveillance system can appear here because both central and regional levels are involved.
14 regions participated in the study with a response rate of 70 %. This response rate is acceptable as long as it is above 60 %, as noted in the Canadian Medical Association journal's editorial policy. [14] There is no complete consensus about the acceptable response rate of cross-sectional studies like in surveys, although some agencies ask for a response rate equal to or over 75 %. [15,16] A response rate of over 50 % is considered adequate. [17,18] In the current study, 70 % response rate was accepted.
Even among the participants, some data were incomplete, which affected the validity and quality of the study.
In the regional infection control department, 78.57 % of participants admitted that there is a national manual for surveillance and response systems for HAIs and HAIOs. One coordinator sent the manual by email, which proved its existence. The differences in answers can be attributed to a lack of information or misunderstanding. The manual was updated in 2017 for HAIs surveillance and in 2018 for HAIOs.
The surveillance manual has a list of priority diseases, including  The response rate can refer to some extent to a low acceptability rate.

[20]
Regarding the case confirmation indicator, 92.86 % of the regional level admitted that there is a capacity to transport specimens to a higher level laboratory, and there are guidelines for specimen This will positively increase the sensitivity and predictive value, enhancing the detection process of HAIs and their outbreaks.
A surveillance register is a powerful tool to collect and store data that can monitor disease trends, including healthcare-associated diseases.
The data help to provide information on incidence rates, remission, exacerbation, prevalence, and survival. It is also often used in data collection on risk factors and prevention programs, diagnosis, treatment approaches, and mortality. [21] Registration also reflects the data quality and validity. There is also impairment in timelines characteristic of monthly reporting. Consequently, there might be an iceberg phenomenon at the service level due to underreporting process and lack of timeliness.
Timely reporting is a significant measure of the performance of public health surveillance systems. It is known that the timeliness depends on disease nature (e.g., rapid onset and brief course), the purpose of use of the data, and the public health system level. Even in developed countries with high public health system levels like the USA, timelines lag. [25] Rapid access to electronic representations of health events (e.g., laboratory reports, patient records, or health care claims) provides excellent opportunities for more timely and complete surveillance.
Availability of simple forms, guidelines, and posters showing reporting system and designation of surveillance focal person can improve timely reports substantially. [26,27] In most regions, 85-90 % have data analysis by time, place, person (age and gender), and trend, but 57-71 % said there is data analysis for causes, vehicles, and contributing factors. This means that although there is good data analysis at the regional level, improvement is required. This core function (data analysis) indicates that the representativeness characteristic is present, which helps in the detection of outbreaks if the event is above the expected level. [19] Only 63.64 % of the HAIOs were thoroughly investigated with the identified risk factors and causative agents. The findings of those investigated outbreaks were used to improve the outbreak investigation. This finding indicates a significant defect in the investigating process.
As scientifically known, three types of investigation must be conducted: epidemiological, laboratory, and environmental. The defect here is in the mid-level, but there is a need to evaluate this level to ensure data reliability.
There might have been confusion between feedback and outbreak investigation reports.
Feedbacks represent one of the primary components of the surveillance system (dissemination).
Feedbacks play a crucial role in improving the practice. They are essential in maintaining a spirit of collaboration among the public health and medical communities and improving reporting to the surveillance system. Making the health departments accessible at all times to receive reports and provide consultation and maintaining current directories of persons for dissemination of surveillance data, alerts, and recommendations will ease the achievement of core activities of surveillance systems, namely data collection, analysis, and dissemination of information about health events under surveillance. [26,29] The ministerial surveillance team did visits to 35.71 % of the regions in the past year, which is lower than the visits of the regional surveillance team to the service level (hospitals Regarding resources indicator, the regional level has good communication and data management. The main problem is a shortage of staff to cover program duties and transportation. Half of the regions did not have enough staff or vehicles during the outbreak investigation. This leads to a late response to outbreak events. It also minimizes the efficiency of regional teams in facing their duties. It also reduces the acceptability of the surveillance system. Availability of resources and diagnostic and therapeutic services might be effective incentives that healthcare providers need. [26] More than 85 % of the regions have good collaboration and coordination with central and service levels regarding cooperation and coordination. One of the striking features is that only 50 % of regional coordinators are satisfied with the surveillance system.
Satisfaction is an essential characteristic of the surveillance system because it reflects its acceptability and performance among all system functions.
From the discussion, it is clear that the study results answered the research question that the surveillance and response systems of HAIs and HAIOs in regions are functioning but not ideally. Hence they need support and improvement.
The results could not reject the research hypothesis that the surveillance and response systems of HAIs and HAIOs in the regions are ineffective, not sensitive, inconsistent, and not timely. There are significant defects in core and support functions at the regional level.
(Tables 5A and 5B)  Limitation: Difficulty in carrying out an observational evaluation.
No evaluation of the primary or service level could affect representativeness. There is difficulty in comparing our study with other studies.

Conclusion:
Regional level: 1-The surveillance and response systems of HAIs and HAIOs are working at the regional level. 9-Supervisory visits were markedly low.

Therefore
Core functions of surveillance and response systems of HAIs and HAIOs were not fulfilled entirely but were mainly present and needed improvement.
The supporting functions of the surveillance and response systems for HAIs and HAIOs were doing less than what is expected in KSA.
These indicators and others indicate that significant gaps in the surveillance and response systems of HAIs and HAIOs in Saudi Arabia (regional level) must be filled as soon as possible.

Recommendations:
1-Update the existing systems for surveillance and outbreaks in English and Arabic languages with the engagement of stakeholders.
2-Developing a unified definition of HAI and a list of priority infections based on the most prevalent organisms during the past 10 years.