Table 1.

Challenges and Strategies Employed in Implementing the Unidentified Liver Disease Active Surveillance System in Tigray, Ethiopia

Challenges	Strategies	Outcomes	Lessons Learned
Unknown etiology and absence of diagnostic test
Unknown etiology No confirmatory diagnostic test Limited and varying clinical expertise among healthcare workers	Developed simple case definitions EHNRI trained staff on case detection and reporting Health extension workers -Referred suspect cases to health centers for confirmation -Educated community on ULD	Health extension workers -Increased ULD awareness -Identified cases -Referred cases for treatment	Frontline staff were critical in increasing ULD awareness in the community and conducting active case finding.
Implementation of traditional paper-reporting system
Electronic reporting was not feasible -Limited telecommunication -Unavailability of electricity Paper reporting was challenging -Long distances and challenging terrain -Lack of transportation -Lack of reliable postal services -Shortage of reporting forms	Surveillance staff at health facilities -Travelled up to 40km by foot or available transport to conduct paper reporting -Copied forms at their own cost -Hand-wrote reports when forms ran out NW Zonal staff visited district offices and health facilities to actively collect missing reports not captured by passive reporting	Frontline surveillance staff successfully delivered paper surveillance forms to report cases Active collection of missing reports improved timeliness	Dedication of the frontline staff was critical to ensure case reporting. Active collection of missing reports overcame transportation issues.
Staff shortage and turnover
Limited number of surveillance staff Reporting often stopped when focal surveillance staff were away High staff turnover	Health facilities trained new staff who had not undergone official training Shire agricultural team was assigned a dual role and oversaw the surveillance activities in NW Zonal office	Many staff requested regular official training Placement of Shire agriculture team in NW Zonal office was effective in collecting missing reports, but their assignment was temporary	Regular official training will be necessary to address staff turnover and train back-up staff.