EWARS is a hospital-based sentinel surveillance system. It grew out of an interest in tracking cases of poliomyelitis and it includes six diseases: three vaccine-preventable diseases or VPDs (polio, measles and neonatal tetanus or NNT) and three vector-borne diseases (malaria, kala-azar (KA), and Japanese Encephalitis (JE). It was designed to provide more timely information to the decision makers to facilitate early response. Subsequently, with the USAID interest in VBD, it extended to report on Malaria, KA and JE as well. The existing Health Management Information System (HMIS) in Nepal, as elsewhere, is not designed to provide timely information or facilitate early response. In addition, hospital cases were inadequately investigated, and there were inadequate definitions and guidelines for diagnosis, investigation and management of diseases. There was an inadequate link between hospitals and the public health infrastructure and actions.

EWARS was started in 1996, and the Epidemiology and Disease Control Division (EDCD) of the MOH has been the implementing agency. The number of sentinel sites has grown to the current 28, and they are expected to report every week on the number of cases and/or deaths (including “zero” reports) of the six priority diseases. EDCD compiles the information from the reporting districts and publishes a weekly EWARS Bulletin.

In response to the need for epidemiological surveillance of priority communicable diseases, the Nepali government’s Department of Health Services of His Majesty’s Government (HMG) designed and launched EWARS in 1996. The Epidemiology and Disease Control Division (EDCD) was designated as the implementing agency.

EWARS was viewed as a means to supplement and complement the HMIS by providing timely reporting for the early detection of selected vector-borne and vaccine-preventable diseases, as well as other diseases with outbreak potential.

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). EWARS 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 (including “zero” reports1) 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 was designed to complement the HMIS, which already contains a large amount of information and responds to numerous needs. The HMIS report is submitted on a monthly basis, and thus is not conducive for use as an early warning system. In contrast, EWARS provided a systematic collection, collation, analysis, interpretation, and dissemination of data on six identified diseases for immediate public health action, monitoring, and timely response to outbreaks of these priority diseases.

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. In the same year, the first workshop on prevention and control of vector-borne diseases was held in Kathmandu.

Recommendations on policies and strategies for prevention and control of VBDs were formulated and launched. The emergence and reemergence of these diseases served as a stimulus for the initiation of EWARS. A year later, in 1998, EWARS was expanded to 24 sites, in 2002 to 26 sites, and 2003 to 28 sites