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ISDS 2012 Conference Abstracts

Evaluation of the Pyrrolizidine Alkaloid Induced Liver
Disease (PAILD) Active Surveillance System in Tigray,
Ethiopia
Cindy Chiu*1, Danielle Buttke1, Girmay Welde2, Richard Luce3, Asfaw Debela4, Amsalu
Bitew5, Tesfaye Bayleyegn1, Sara Vagi1, Matthew Murphy1, Daniel Woldemichael2, Teshale
Seboxa6, Gidey G. Libanos7, Zeyeda Beyene7, Yohannes G. Hawaria7, Daddi Jimma4, Israel
Tareke8, Danielle Rentz1 and Colleen Martin1

1Centers for Disease Control and Prevention, Atlanta, GA, USA; 2Tigray Agriculture Bureau, Tigray, Ethiopia; 3Centers for Disease
Control and Prevention, Addis Ababa, Ethiopia; 4Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia; 5Suhul
Hospital, Tigray, Ethiopia; 6Addis Ababa University, Addis Ababa, Ethiopia; 7Tigray Regional Health Bureau, Tigray, Ethiopia; 8World
Health Organization, Addis Ababa, Ethiopia

Objective
To describe the results of the evaluation of the PAILD active sur-

veillance system and lessons learned for similar surveillance efforts
in a resource-limited setting.

Introduction
A liver disease of unknown etiology, called unknown liver disease

(ULD) by the community, was first identified in 2002 in Tigray; a
rugged, semi-arid, mountainous region that is considered one of the
most drought-prone and food insecure regions of Ethiopia. ULD is a
chronic condition characterized by epigastric pain, abdominal dis-
tention, ascites, emaciation, and hepato/splenomegaly. In 2005, the
Ethiopian Health and Nutritional Research Institute was assigned by
the Ethiopia Ministry of Health to assist the Tigray Regional Health
Bureau and oversee the disease investigation. In 2008, Centers for
Disease Control and Prevention (CDC) assisted the Ethiopian team
and jointly developed the surveillance tools. The surveillance system
was implemented in 2009 with the objectives to determine the mag-
nitude and distribution of the disease; identify disease trends; detect
cases to provide them with clinical care; and inform health officials
and funding bodies for resource allocation.  After several investiga-
tions, a local plant containing a particular type of pyrrolizidine alka-
loid (PA) toxin that contaminated local foodstuffs was identified as
the etiologic agent, and ULD was renamed PAILD in 2011.

Methods
From 20 September to 1 October 2011, we conducted site visits,

held semi-structured interviews with 20 staff members, reviewed re-
porting materials, and summarized the information flow including
data collection, reporting, analysis, and dissemination.

Results
This surveillance system was implemented in 13 rural, resource-

limited districts in the NW, Central and Western Zones. The system
identified a total of 1033 cases, including 314 deaths, as of Septem-
ber 2011; guided medication distribution to the health facilities;
served as a registry for patient follow up; and provided decision-mak-

ers with information needed to allocate resources. A large-scale train-
ing was conducted in 2010; however, high staff turnover and a lack
of backup surveillance staff at each site suggested that additional
training may be needed. Due to the absence of a diagnostic test, the
case definition was very simple to enable frontline staff in the com-
munities and at the health posts/centers to identify disease cases.
These individuals travelled long distances by foot to deliver paper
surveillance forms to the district health offices. A surveillance team
placed in the NW Zonal office collected missing reports from the
health facilities given limited transportation; however they have left
since this evaluation. Information from the surveillance system was
shared with partner agencies at the national level every 3 to 6 months;
however, this information was not shared with frontline staff.

Conclusions
The PAILD Active Surveillance System met its objectives as orig-

inally defined. Evaluation of this unique surveillance system for a
chronic disease with unknown cause in a resource-limited setting pro-
vides several lessons that can inform similar surveillance efforts. On-
going logistical challenges (e.g., shortage of paper forms, lack of
transportation, and long distances between locations) complicated
data collection and reporting. While electronic reporting may have
helped overcome some of these difficulties, it was not feasible in this
setting. Frontline staff identified cases in the community so that they
could receive treatment; these key staff can be further incentivized
by receiving regular training and surveillance reports.  Ongoing sup-
port will be critical to overcome these unique challenges to ensure
continual disease monitoring as interventions to disrupt PA exposure
are implemented in the community.

Keywords
Evaluation; Pyrrolizidine Alkaloid Induced Liver Disease; Active
Surveillance System; Ethiopia

*Cindy Chiu
E-mail: vic2@cdc.gov

Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 5(1):e167, 2013