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Early Warning Reporting System (EWARS), Nepal

by Public Health Update
Early Warning Reporting System (EWARS) is a hospital-based sentinel surveillance system currently operational in 40 hospitals throughout Nepal. EWARS is designed to complement the country’s Health Management Information System (HMIS) by providing timely reporting for the early 4 detection of selected vector-borne, water and food borne diseases with outbreak potential. 
The hospital based reporting provides timely signal or alert and early detection of possible outbreak due to increased number of cases in the community leading to continuous transmission of the disease for timely response. This dynamics is lacking with HMIS being a monthly reporting system. The main objective of EWARS is to strengthen the flow of information on vector borne and other outbreak prone infectious diseases from the districts; and to facilitate prompt outbreak response to be carried out by Rapid Response Teams (RRTs) at Central, Regional and District level, which can be mobilized at short notice to support the local levels (DHO/HP/SHP) in case investigation and outbreak control activities. In the broader perspective, it also aids on program planning, evaluation, and the formulation of research hypotheses and to disseminate data/information on infectious diseases through appropriate feedback system It was established in 1997 first in 8 sentinel sites and expanded to 24 sites in 1998, 26 sites in 2002, 28 sites in 2003 and 40 sites in 2008. 

The EWARS mainly focuses on the weekly reporting of number of cases and deaths (including “zero” reports) of six priority diseases: three vector-borne diseases Malaria, Kala-azar and Dengue and three outbreak potential diseases Acute Gastroenteritis (AGE), Cholera and Severe Acute Respiratory Infection (SARI). It equally focuses on immediate reporting (to be reported within 24 hours of diagnosis) of one confirmed case of Cholera, and severe and complicated Malaria and one suspect/clinical case of Dengue as well as 5 or more than 5 cases of AGE and SARI from the same geographical locality in a one week period. Based on the experiences of reported outbreaks of acute diarrhoeal diseases and influenza by several districts, these two diseases are included for reporting in EWARS from the year 2005. Likewise, Dengue and DHF case reporting will be required to be reported in EWARS due to its high potential of impending epidemics. Other communicable diseases besides these six prioritized diseases also need to be reported in EWARS, whenever the numbers of cases exceed the expected level.

Information Flow Mechanism in EWARS:

The four basic elements of surveillance that were the cornerstones for EWARS development were 
  1. a mechanism for hospital inpatient-ward-based case detection, 
  2. laboratories for identifying and characterizing microbes, 
  3. information systems, and 
  4. response (information feedback and mobilization of investigative and control efforts). 

Objectives were

  • to develop a comprehensive, computerized database of infectious diseases of public health importance
  • to monitor and describe trends of infectious diseases through a sentinel surveillance network of hospitals followed by public health action and research
  • to receive early warning signals of diseases under surveillance and to detect outbreaks
  • to instigate a concerted approach to outbreak preparedness, investigation and response 
  • to disseminate data/information on infectious diseases through an appropriate feedback system. 
The main focus of EWARS was reporting on a weekly basis the number of cases and deaths of the six priority diseases. These diseases were selected based on a number of criteria: widespread distribution; major causes of morbidity, mortality and disability; potential for causing outbreaks; already monitored under national programs; amenable to control through cost-effective means; and being a global priority for elimination, eradication and/or control. The selected EWARS diseases were divided into two groups: 
(1) vaccine-preventable diseases (VPDs), which include acute flaccid paralysis (AFP), measles, and NNT; and 
(2) vector-borne diseases (VBDs), which include KA, JE, and malaria. In addition, in the case of an outbreak, EWARS includes the immediate reporting of a single suspected/probable/confirmed case of AFP, NNT, severe and complicated malaria, and JE, as well as ten cases of measles from the same locality within 24 hours of diagnosis. Other communicable diseases are also reported periodically in EWARS.

EWARS began in September 1996 with the development of guidelines and the selection of eight sentinel sites (SSs). Training of the medical records assistants (MRAs) took place several months later, in November. Between December 1996 and March 1997 the SSs were visited to ensure that everything was in place so that EWARS could start functioning in April 1997.



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