MMOH established HMIS as a routine reporting disease surveillance system several years ago, and the system has been fully functioning in almost all levels of hospitals. However, hospitals, especially at the secondary referral level, should consider strengthening microbiological surveillance because of weakness in laboratory capacity at such hospitals. Microbiological surveillance is important for early detection of public health emergencies, especially with regard to communicable disease outbreaks. Currently, there are only about 20-30% of hospitals that have microbiological surveillance systems important for investigation of public health emergencies, compared to 64.5% of hospitals in China .
The World Health Organization recommends that emergency surveillance should include bloody diarrhea, acute watery diarrhea and suspected cholera, acute respiratory tract infection (ARI), measles, meningitis, HIV/AIDS, sexually transmitted infections, tuberculosis, and neonatal tetanus . Setting up of EWAR with participation of national and international organizations working in public health emergency response is a best practice for public health emergency management and should be set up as soon as possible as part of public health emergency management. These diseases are comparable to those included in Myanmar's routine surveillance system, but there is room for improvement in areas such as recording and calculation of timeliness for surveillance and sensitivity for outbreak detection . HMIS reporting is a passive surveillance system, which includes such limitations such as under-reporting; potential unreliability because of dependence on basic health staff for data collection, and incompleteness of data due to underutilization and difficulties of accessing health services in some rural areas. However, it is also necessary to set up the database for logistic capacity and drug supply within the health sector in cooperation with other organizations working in public health emergencies .
The national surveillance data taken together with the EWAR reports suggested that morbidity of diarrhea, dysentery and ARI increased significantly for about 3 months after Cyclone Nargis, but the incidence of other diseases did not deviate much from normal levels or seasonal patterns, compared to 2007 and 2009. The increases observed during the months after Cyclone Nargis included some, but not all, of the outbreak-prone diseases that have been documented to increase following other disaster incidents elsewhere----ARI, diarrheal diseases, measles, malaria in endemic areas, epidemic meningococcal disease, dengue, tuberculosis, tetanus, pneumonia, relapsing fever, yellow fever, and typhus [6, 17]. Early diagnosis and prompt treatment by trained staff that use standard protocols at all health facilities improves the management of communicable diseases and mitigates the health impact of a natural disaster . Thus, the relatively high availability of drugs for common diseases in risk areas and the strengthened preparation for disaster management and health services offered by governmental programs, international organizations and NGOs might help explain why the morbidity and mortality of common communicable diseases were lower than might have been expected after the Nargis incident.
The country still needs to reach its targets for routine disease control programs. For example, the tuberculosis program reached its overall targets of case detection and treatment success rates, but these levels varied in different townships. More efforts are needed in townships that did not reach the national targets. While PMTCT coverage improved during the study period, healthcare providers noted that PMTCT services should be secured at all townships by national health programs with financial and technical support. This involves many stakeholders that manage PMTCT services in the country. While measles vaccination coverage was slightly less than 90% in affected areas and disease incidence in those areas did not increase post-Nargis, it has been suggested that if measles vaccination coverage rates are lower than 90%, measles vaccination should be given priority to prevent an outbreak of measles in emergency situations [5, 6]. In all, it was found that coverage for all immunizations was slightly lower after the Nargis incident in 2009 compared to 2008. Immunization services should be restored and sustained as part of the routine National Health Program with involvement of donor agencies and township health departments.
Community awareness programs should be strengthened because community awareness of early treatment and proper case management is essential to reducing the impact of communicable diseases such as diarrheal diseases, ARI, malaria and dengue . Almost all of the organizations surveyed for this study distributed several IEC materials regarding communicable diseases; however, most of the participants in the focus group discussions reported not being interested in health education programs. Evaluation of the effectiveness of these health education programs should be carried out to identify ways to improve such efforts in future emergencies.
Utilization of health services, marked by indicators such as general clinic attendance, improved between 2007 and 2009. However, rates were still quite low in comparison with HMIS target achievement of 50%. Clinic attendance rates of some townships were less than 15% while TCG survey also reported that health services utilization did not reach the Sphere target of 4 visits per person per year [10, 11]. It remains necessary to research factors influencing the utilization of health services. Sanitary latrine coverage in Nargis-affected townships was slightly lower than the national sanitary latrine coverage of around 80% and fell sharply following the incident. The distribution of water and sanitation services was quite varied across the affected communities. The water and sanitation program should be strengthened in townships which are below the national average, through cooperation among government and non-government stakeholders and the respective communities.