The Early Warning and Reporting System (EWARS) in Nepal

The Early Warning and Reporting System (EWARS) is one component of the surveillance systems of communicable diseases. In this system, when certain identified hospitals “sentinel centres” identifies the case of specific diseases of epidemic potential, this should be notified to surveillance center weekly or immediately within 24 hours in certain conditions.

In Nepal EWARS comes under the epidemiology and disease control division (EDCD) and collaborates with the Vector Borne Research and Training Centre (VBDRTC). Surveillance and Research Section of EDCD is responsible in managing early warning and reporting system. It was started as a hospital based, sentinel system in 1997. Now, it is based in 48 hospitals, (out of 81 identified sites) throughout Nepal. So far, the EWARS mainly focuses on the weekly reporting of number of cases and deaths (including "zero" reports) of six priority diseases/syndromes—Malaria, Kala-azar, Dengue, Acute Gastroenteritis (AGE), Cholera and Severe Acute Respiratory Infection (SARI), and other epidemic potential diseases/syndromes (like enteric fever, leptospirosis, hydrophobia).

The sentinel hospitals send weekly reports (and immediate reports in case of an outbreak) to the VBDRTC where reports are consolidated, forwarded to EDCD and published in the weekly EWARS bulletin on every Sunday.

It furthermore focuses on immediate reporting (to be reported within 24 hours of diagnosis) of one confirmed case of Cholera, Kala-azar, severe and complicated Malaria and one suspected/clinical case of Dengue as well as 5 or more cases of AGE and SARI from the same geographical locality in one-week period.

If the EWARS is effectively operational, Rapid Response Teams (RRTs) can be mobilized at short notice to facilitate prompt outbreak response at Central, Regional and District level. They can also support local level health institutions for investigation and outbreak control activities. 

The early warning functions of surveillance are fundamental for national, regional and global health security. Recent outbreaks such as the severe acute respiratory syndrome (SARS) and avian influenza, and potential threats from biological and chemical agents, demonstrate the importance of effective national surveillance and response systems.

An early warning and reporting system serves to: 

• Identify diseases with epidemic potential in a timely manner 
• Detect outbreaks through 'flagging' unusual events and triggering an appropriate investigation 
• Inform appropriate and effective public health responses 
• Determine the distribution and spread of disease 
• Provide information to categorize the outbreak as of national or international importance 
• Provide data to evaluate control measures.

Possible Loopholes in EWARS in Nepal

For effective functining of EWARS in Health System, there should be strong commitment from all the stakeholders. Many hospitals haven't reported the report in timely manner and many have submitted incomplete reports, which hinders its completeness and the scenario remains questionable. Furthermore, sometimes the disease may remain unnoticed threatening the whole population when the EWARS  isn't complete.
The identified hospitals need to fulfill all the prerequisites  to be sentinel centre for the disease. EDCD should provide timely monitoring and evaluation and If the hospitals are not reporting, they need to identify the reason behind it and present in the weekly bulletin as well. The reasons might be inadequate manpower, lack of trained manpower, lack of diagnostic facilities or willingness.  
To get Weekly Bulletin on EWARS from EDCD, Nepal: Click here

Sources: 

1. WHO. Communicable disease surveillance and response systems: Guide to monitoring and evaluating. http://www.who.int/csr/resources/publications/surveillance/WHO_CDS_EPR_LYO_2006_2.pdf
2.  MOHP, DOHS, Epidemiology and Disease control Division. Early Warning and Reporting System, Weekly Buletin, 17th Epidemiological week. 8th May 2016. Kathmandu, Nepal
3. WHO. Expanded Programme on Immunization and Vaccine Preventable Disease (VPD) Surveillance Review. 15-27 April 2010. Nepal