# Evaluation of the implementation of the EWARS Mobile epidemiological surveillance tool in Sudanese refugee camps in Eastern Chad: a retrospective and population-based surveillance study

## TL;DR

This study evaluates the use of a mobile surveillance tool in Sudanese refugee camps in Chad to track and respond to disease outbreaks among children.

## Contribution

The study provides a novel evaluation of EWARS Mobile's implementation in a severe humanitarian crisis setting.

## Key findings

- 1,645 alerts were reported, covering diseases like acute flaccid paralysis and acute watery diarrhea in children.
- Case reporting and alert recording achieved ≥80% completion rate, but timeliness was suboptimal.
- Epidemic curves revealed multiple outbreak types, including point and common sources of disease spread.

## Abstract

The escalation of the conflict in Sudan has created a major humanitarian challenge for neighboring countries, especially in the Eastern regions of Chad. This humanitarian setting's health needs are unique in that they are more vulnerable to both outbreak-prone disease and a lack of essential services. To address these challenges, the World Health Organization has supported implementing the Early Warning Alert and Response System (EWARS) Mobile. The purpose of this study was to evaluate the application of the EWARS Mobile epidemiological surveillance tool in Sudanese children’s refugees in Eastern Chad.

This was a retrospective and population-based surveillance study that provided an overview of the pattern of cases and deaths in time and space related to potential outbreaks.

In total, 1,645 alerts were reported among children in vulnerable provinces of Quaddai, Sila, and Wadi Fira. There were 41,738 alerted cases and 236 deaths, for a 0.56% projected fatality rate. The EWARS Mobile successfully reported alerted increases in cases of acute flaccid paralysis (AFP), acute jaundice syndrome (AJS), acute respiratory infection (ARI), acute watery diarrhea in children (AWD), measles, meningitis, diphtheria, neonatal tetanus (NT), dengue, dysentery, and atypical events in vulnerable children in time and space. Case reporting, alert recording, and weekly reporting were completed successfully at all levels (camps, district, zone, and province) (≥80% completion rate). In contrast, the timeliness of alert reporting, weekly reporting, and probable outbreaks did not perform well across levels (≥80% timeliness rate). Epidemic curves indicated multiple probable outbreak types, characterized by a point source (AJS and AWD under 5 years), common source (AWD in 5 years and above), propagated source (ARI and dysentery), and intermittent source (AFP, measles, meningitis, diphtheria, NT, and unusual events). The sensitivity and positive predictive value were estimated at 81% (79%–83%) and 72.0% (68%–75%), respectively.

The EWARS Mobile is a practical solution for Eastern Chad provinces to implement throughout the pre-epidemic and outbreak periods in vulnerable children in this severe humanitarian crisis. However, efforts should be made to improve timeliness indicators at all subnational levels and incorporate alarm indicators.