Evaluation of injury surveillance system in Hajj 1425 Hijra

The pilgrimage to Makkah (Hajj) is an annual congregation of more than 2 million Muslim pilgrims, the contact among pilgrims and high population density aggravates exposure of hajjes to the risk of injuries. In the past, injuries have been reported as component of the routine health care facility reporting system in Hajj, recently it has been identified as a separate entity in patient management system since Hajj 1423 H. This study was conducted as a cross sectional study by a team from Field Epidemiology Training Program (PEI P) to evaluate different components of the Injury Surveillance System (ISS) during Hajj 1425 Hijra (2005 G).

A questionnaire was designed as combined observation/interview based, to record the existing organizational structure, system of injury registration and reporting, and an interview schedule for directors and health workers dealing with injured patients at first contact level in the facility to assess their knowledge and practices about injury reporting system and to assess the completeness of the injury management/ data collection forms. A team of two physicians visited all the participating health facilities i.e. all the hospitals in Makkah and dispensaries in Haram; and all the hospitals and 6 randomly selected Health Centers in Mina. During their visit they observed the system in general, interviewed each health facility director; one physician and one nurse paramedical worker and reviewed official injury data collection forms, in accordance with the methodology mentioned earlier. Data collection was done from 2nd to 6th of Dhu'ul Hajja, 1425 in Makkah and from 7th to 12th Dhu'ul Hajja, 1425 in Mina.

As shown in table I, the injured patient were received at reception desk to register before getting medical service in most of the facilities studied except Mina general hospital, Mina PHC No. 1 and Haram dispensaries where patient immediately received medical services without registration. Specially designed Hajj injury forms were utilized in all the Mina hospitals and 4 PHCs in Mina, while all Makkah hospitals and 2 PHCs in Mina used the General Hajj OPD form to manage the injured patients. However, the Haram dispensaries did not use any forms, and just entered all the injured patients in a register along with other patients. In all the Mina and Makkah hospitals, data is entered into computers which are directly linked to the central computers at Makkah Regional Health Directorate and Ministry of Health Riyadh. In smaller facilities reports are sent by either telephone or fax. None of the facilities prepared a separate report detailing injuries, however King Abdul Aziz hospital Makkah, King Faisal Hospital Makkah and 2 health centers in Mina reported the injuries distinctly in their regular reports. Detailed data recorded in the new special injury patient management form was not used in reports of the facilities using those forms. In all the facilities visited, reports were sent to the higher authorities within the previous 12 hours. In Makkah regional directorate, Makkah hospitals and Mina Al Wadi hospital facilities existed to generate reports on real-time data, including general injury information. No communication with non-MOH facilities existed regarding reporting of injured patients.

The forms used for management of injured patients were evaluated and among the 180 forms evaluated in Mina health centers, 61.1% were filled for the location and type of injury and among the 90 forms evaluated in Makkah hospitals 90% had these sections filled. Among the 120 forms evaluated in Mina hospitals, 95% filled the code for provisional diagnosis of the patients (as there was no separate section for injuries in these forms).

Injury is a serious public health issue with a major impact on lives, as a major cause of long and short term disability.[1] Development of a special surveillance system for injuries during Hajj was a major initiative taken by the Ministry of Health. Selecting injuries as an independent entity in the routine surveillance system, which has previously focused on communicable diseases, was based on the dissimilar causation of injuries and preventive efforts required to minimize their occurrence and impact.

The Centers for Disease Control and Prevention, Atlanta, USA, recommends attributes such as simplicity, flexibility, acceptability, sensitivity, representativeness and timeliness for evaluating any surveillance system .[2]

Regarding simplicity, a surveillance system should produce all the information needed for informed decision making, in the simplest and most straight forward way possible without wastage of staff time by requiring repeated entry of the same information.[2,3] This study showed that in the new data collection instruments, the amount of information has been kept to a minimum and the information transmission system was also quite straight forward. On the other hand, absence of cause of injury, its severity and part of body/organs involved limit the usefulness of information.

The surveillance system is also expected to be sensitive i.e. able to detect all injury cases.[2-4] However, this study reflects that the existing system has a number of sensitivity issues, such as the absence of links to the non-MOH health facilities like Hamla doctors, foreign medical missions; and cases transferred to Makkah directly, especially for severe cases. Furthermore, most of the system hardly reports injuries as a distinct entity, even where it is reported it does not go beyond the total number of cases seen and even the small amount of information available in the forms does not reach the decision makers.

Completeness is another issue of quality in surveillance. As observed in this study the information related to patient identification is generally complete but had some lapses in areas which enable the health manager to understand the injury pattern or the outcome. Apparently, timeliness of the information flow upwards is not a problem, as the reports including injury cases are transmitted almost on 1-2 hourly basis in PHCs, while the data in hospitals is transmitted instantaneously to all concerned through the computer network.

The new ISS has been established in Hajj for over 2 years. Our study revealed that its implementation is still patchy. Efficient working of a surveillance although depends a lot on a good design, in the field, however, it primarily depends on the manpower involved in its implementation, which in turn is the product of training and motivation of staff. Unfortunately, it appears that in this ISS training the staff have been ignored completely. The new hajj ISS is only working in Mina PHCs at present; and except for the timeliness issue, it needs a lot of modification to improve its deficient areas especially incomplete coverage, non-availability of standard operating procures, poor staff training, weak supervisory and feedback mechanism, and lack of communication with non-MOH facilities.