Even before the current war in Sudan, the immunization program was facing numerous challenges in combating disease outbreaks. This included outbreaks of cVDPV2, measles, diphtheria, pertussis, and neonatal tetanus, all of which indicated significant gaps in the delivery of essential vaccines to rural areas. Surveillance systems in early detection remained weak due to inadequate resources, and capacity-building initiatives had not been effectively implemented. Outbreak investigation and response were hampered by limited resources, leading to delayed detection and management of disease outbreaks. Three years into the conflict, Sudan’s health system remains severely damaged, while at the same time struggling with more disease outbreaks. The need for robust surveillance for early detection and response became more urgent than ever.

In response to this urgent need, greater investment has been made in building capacities for surveillance and outbreak investigation, with a focus on operating effectively in emergency situations and amid conflict. This was achieved through two fronts standing together: on one side, empowering health workers at the periphery: those closest to where diseases emerge and spread, often in areas disconnected from central systems; and on the other side, engaging communities not as passive recipients of services but as active participants in disease detection and reporting. Together, these two forces formed a stronger frontline, bridging the gap between the health system and the people it serves.

Strengthening District-Level Immunization Surveillance: The Public Health Empowerment Program- Expanded Program on Immunization (PHEP-EPI)

In October 2024, EMPHNET, with support from Gavi, the Vaccine Alliance under the leadership of the Federal Ministry of Health (FMoH) accelerated efforts to strengthen Sudan’s immunization program, including routine immunization services, surveillance, and outbreak investigation and response. This overarching aim is being realized by strengthening the technical capacities of Surveillance/EPI officers to enhance immunization, surveillance, and outbreaks investigation and response through supporting the PHEP-EPI in the context of emergency and conflict.

With a focus on the frontlines and the district officers, the training is designed to build their capacity in handling surveillance data and integrating it with routine data. This is essential, as it can greatly enhance the quality of data and contribute to disease prevention and control efforts. The training program builds the immunization officers’ capacity to undertake essential tasks that support immunization in outbreak investigation and response, writing supervisory reports, and providing more comprehensive training encompassing all VPDs of concern in the country, including ZDC and immunization equity.

When I supported the PHEP-EPI, we had to adapt the curriculum during a very difficult time to fit the country’s context and needs. This  was essential, and it played a key role in guiding the process from design through evaluation. The program was implemented at the periphery, in direct contact with communities. This made it possible to conduct fieldwork and achieve tangible results on the ground. One of its strongest features was the focus on community engagement. The program became especially important when outbreaks increased during the conflict. It gave us a way to respond quickly, strengthen health promotion, and detect diseases early through direct links with the community. - Dr. Fatih Elmalik, Technical Advisor, EMPHNET’s Sudan Country Office

Impact of the PHEP-EPI in the Ongoing Conflict

PHEP-EPI residents/graduates took part in investigating diseases such as diphtheria and measles, strengthening local capacity for surveillance and outbreak management. They engaged in community-based surveillance, case detection, and health education, marking an important shift toward a more integrated approach to public health in which trained personnel mobilized resources and worked directly with communities. Residents/graduates applied their skills and investigated 21 outbreaks, while also contributing to decision-making processes within their localities. They also participated in field visits introduced through the training curriculum, enabling them to contextualize their learning and put theoretical knowledge into practice. Additionally, they strengthened locality-level surveillance, improved AEFI reporting, and enhanced community engagement, while also contributing to better data quality, analysis, and use in decision-making.

The findings from formal evaluation of the program provided compelling evidence of the effectiveness of the training workshops on enhancing public health knowledge, skills, and confidence among program participants. The significant improvement in pre- and post-test scores across both workshops indicates that the educational interventions were successful in achieving their primary objective: increasing residents' understanding of public health concepts and practices. The shift in participants' self-assessment of skills from beginner levels to proficient and advanced categories highlights the workshops' impact on their perceived competencies. The positive feedback from supervisors regarding the graduates' involvement in outbreak investigations and public health responses underscores the training's relevance to real-world applications. - Dr. Fatih Elmalik, Technical Advisor, EMPHNET’s Sudan Country Office

The PHEP-EPI trainees achieved so much on the ground. They launched locally driven projects across states, carried out home visits, and even revived government surveillance channels at the locality level. In Gedaref State, one trainee initiated a community-led measles awareness campaign, organizing mobile sessions, tracking defaulters, and conducting household visits, which led to improved vaccination rates. In Atbara city, another trainee went door-to-door and helped detect and control diphtheria and whooping cough cases. These examples show how simple, community-based actions can make a real difference in outbreak control. - Dr. Mawahib Moddethir, Community Surveillance Officer

Building Networks and Expanding Community-Based Surveillance

Beyond individual projects, PHEP-EPI residents played a vital role in strengthening community-based surveillance (CBS) as a national early warning system. They contributed to expanding and sustaining networks of community informants across localities and states, building a system that reached more than 500 community informants, covering 15 states across Sudan. This expansion created a critical foundation for community-level disease detection and reporting, even amid conflict-related disruptions.

This expansion was supported by a key approach focused on building the capacity of community informants while ensuring continuous field support. This was achieved through updated CBS manuals and training curricula that incorporated priority diseases. Community volunteers were engaged through structured orientation sessions designed to strengthen their ability to detect, verify, and assess suspected cases at the community level. This capacity building was reinforced through regular supportive supervision visits by EPI state and locality officers, which provided hands-on coaching, addressed implementation challenges, and helped adapt surveillance activities to evolving population movements, including displaced and hard-to-reach communities.

Despite the challenges of war, including widespread population displacement, insecurity, and frequent breakdowns in communication networks, these community informants remained functional and adaptable. Overall accessibility to reporting of suspected VPDs and other priority public health events improved significantly over time, reflecting strengthened engagement and continuous field adaptation by PHEP residents and surveillance teams.

Across Sudan, this growing network enabled the detection and reporting of over 1,300 VPDs alerts, including measles, pertussis, diphtheria, cholera, and AEFI. These reports were systematically integrated into the national surveillance system and supported field verification and response activities in collaboration with state and federal surveillance officers.

In areas such as Central Darfur and West Kordofan, community volunteers re-established surveillance links that had previously collapsed. Across Sudan’s states, volunteers and PHEP residents/graduates became part of a growing system of community-based surveillance. For example, in Al Manaqil, graduate Nada Sati, led a community network that tracked vaccine side effects, recording over 100 cases in a single month. These experiences highlight that community engagement was not an additional element but central to the program. By investing in communities, the program strengthened the foundations of surveillance and enhanced the capacity of the health system to withstand future challenges. When asked about the community engagement component with PHEP-EPI, Dr. Mawahib noted:

The program was not only about responding to outbreaks but also about rebuilding systems. Training PHEP-EPI residents extended beyond health professionals and reached into the community. 

Strengthening Surveillance for Resilience in Times of Conflict

The experience of implementing PHEP-EPI in Sudan shows that even in fragile, conflict-affected settings, it is still possible to build surveillance capacity when district officers and communities work together. By giving health workers the skills they need and involving communities as active partners, the program helped improve outbreak detection and response and also restored trust in immunization services. Graduates led local initiatives, revived surveillance systems, and with the help of community focal points, extended surveillance to reach even the hardest-to-reach areas.