What is Public Health Surveillance?

• Is the ongoing systematic identification, collection, collation,

analysis, and interpretation of disease occurrence and public
health event data to take timely and robust action
• It includes the:
 timely dissemination of resulting information for effective
and appropriate action
• Is essential for planning, implementation, and evaluation of
public health practice

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 Public Health Surveillance Approaches - 1

Passive surveillance:
• A system by which, a health institution receives routine
reports submitted from health facilities:
 Such as hospitals, clinics, public health units, or
community or other sources
• There is no active search for cases
• It includes surveillance of diseases/events using routine
Indicator-based surveillance, Health management and
information system (HMIS)

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 Public Health Surveillance Approaches -2
Active Surveillance:
• An ongoing search for cases in the community or health
facilities
• Involves regular contact with reporting sources by:
 Telephone calls to health care workers at a facility or
laboratory
 Physically moving to the reporting sites
 Conducting records review of data
Examples: 1. Active search for measles and polio cases
2. Finding additional cases during outbreaks

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 Public Health Surveillance Approaches -3

• To ensure robust early warning and prompt

response, the IDSR data collection and analysis
system relies on two main channels of information or
signal generation:
1. Indicator-Based Surveillance (IBS)
2. Event-Based Surveillance (EBS)

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Title of the Presentation
 Types of Public Health Surveillance

• Indicator based surveillance (IBS): is the systematic (regular)

collection, monitoring, analysis and interpretation of structured
data, such as indicators produced by a number of well-
identified, mostly health-based formal sources

• Event-based surveillance (EBS): is the organized collection,

monitoring, assessment and interpretation of mainly
unstructured ad hoc information regarding health events or
risk, which may represent an acute risk to health

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 Indicator based surveillance (IBS) and the
common types used
1. Facility-based surveillance
2. Laboratory-based surveillance
3. Disease-specific (vertical) surveillance
4. Case-base surveillance
5. Community-base surveillance
6. Syndromic surveillance
7. Sentinel surveillance

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 Common types of IBS -1

Facility-based surveillance:

• All reporting units (e.g. health facilities) are required to

report on a weekly, monthly, quarterly or annual basis to
the next level based on the categories of the diseases,
conditions and events
• Required to report immediately, any epidemic prone
disease to the next level

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 Common types of IBS -2

Laboratory-based surveillance:
• Surveillance conducted at laboratories for detecting
events or trends that may not be seen as a problem at
other locations or that originates from laboratory
testing mainly done routinely

• Malaria positivity?

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 Malaria Positivity Rate by District, WK 32, 2020
100.0

90.0

80.0
74.0
Malaria Positivity Rate(%)

69.0
70.0 65.8 64.8
59.8 59.5 59.4 59.1 59.1 58.3 58.2
60.0 57.2 56.3
54.3
50.6
48.9
50.0

40.0

30.0

20.0

10.0

0.0
 Common types of IBS -3

Disease-specific (vertical) surveillance:

• Involves activities aimed at targeted health data for

a specific disease for vertical surveillance

• Examples: Tuberculosis, Malaria and HIV

surveillance systems

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 Common types of IBS -4

Case based surveillance:

• For diseases that are targeted for elimination or
eradication or during confirmed outbreaks, every
individual case identified is reported immediately,
using a case based form to the next level

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 Common types of IBS -5

• Syndromic surveillance:
• An active or passive system that uses Standard Case
Definitions based entirely on clinical features
without any laboratory diagnosis

• Examples: VHF, AFP, STI

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 Common types of IBS -6

Sentinel surveillance:
• A given number of designated health facilities or reporting sites
for early warning and reporting of priority events;
 such as pandemic, epidemic events or other public health
events
• They are usually representative of an area or are in an area of
likely risk for a disease or condition of concern

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 Common types of IBS -7

Community-Based Surveillance (CBS):

• A surveillance system that collects community-based
health information and the entire community
population is under surveillance, and not simply a
segment of the community

• Note: CBS incorporates both Indicator-based and

Event-based surveillance methods

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 Event-Based Surveillance
Versus Indicator-based surveillance
• Unlike indicator-based surveillance, event-based
surveillance is:
 Not based on the routine monitoring of indicators and
automated thresholds for action
 But Based on the screening of all available information
to detect any event happening in the community such
as:
o Unusual disease
o Deaths in humans or animals,
o Unusual clustering of cases, events/conditions

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IBS and EBS as back bone to IDSR Strategy

EBS IBS
• Both are components of Early Warning and Response (EWAR) and Epidemic
Intelligence incorporated in the IDSR strategy
• Both are complimentary with each having a different role to play and purpose
• Pick up alerts to detect small • Monitoring disease trends overtime
outbreaks early • Useful for signalling start of regular
seasonal outbreaks of endemic
diseases using alert and epidemic
thresholds

• Better at picking up alerts • Not useful for smaller events because

indicating outbreaks in areas signals are either averaged out in
where access to healthcare is large data sets, or lost in smaller data
limited sets

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Levels of Applications and Reporting of EBS and IBS in the context of IDSR
At National level:
 EBS implementation using hotlines and media scanning at PHEOC
 Oversees implementation of EBS and IBS at all levels

District level:
• DHMT ensures EBS implementation using hotlines and media scanning
• Supervises implementation of EBS and IBS at health facility and community levels

Sub-district/Health Facility level:

• Health facility managers ensures IBS and EBS implementation at health facilities
• Supervision of EBS and IBS at community level

Community level:
• CBS Focal persons implement EBS and IBS at community level
• Detects and notify alerts to nearest health facilities
•
IDSR Early warning system: Indicator Based Surveillance and Event Based Surveillance
 What is IDSR? -1

• IDSR is a strategy adopted by WHO AFRO member

states in September 1998 for;
• Improving public health surveillance and response
for priority diseases, conditions and events at
community, health facility, district and national level
in African countries

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 Key principles of IDSR
• Integration:
 Refers to harmonizing different methods, software, data
collection forms, standards and case definitions in order to
prevent inconsistent information and maximize efforts
among all disease prevention and control programmes and
stakeholders

• Coordination:
 Refers to working or acting together effectively for the
rational and efficient use of available but limited resources
such as the Health Management Information System (HMIS)
and various disease programs
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CPI-WHE-WHO/AFRO
 Advantages of IDSR Strategy

1. Promotes rational and efficient use of resources by

integrating and streamlining common surveillance
activities and functions

2. Makes surveillance and laboratory data more usable

3. Help public health managers and decision-makers

improve detection and response of priority
diseases/conditions/events

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 Specific objectives of IDSR-1
1. Strengthen the capacity of countries to conduct
effective surveillance activities
2. Integrate multiple surveillance systems so that tools,
personnel and resources are used more efficiently
3. Improve the triangulation and use of information to
detect changes in trend in order to conduct a rapid
response to suspected and confirmed outbreaks;
monitor the impact of interventions

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CPI-WHE-WHO/AFRO
 Specific objectives of IDSR - 2
4. Improve the flow of surveillance information
between and within levels of the health system and
other health systems

5. Build strong laboratory systems and networks at

national, regional and sub- regional levels

6. Trigger epidemiological investigations of reported

public health problems and the implementation of
effective public health interventions

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 Specific objectives of IDSR - 3

7. Mount an effective response to public health

emergencies

8. Increase involvement of clinicians in the surveillance

activities

9. Emphasize community participation in detection,

reporting and response to all public health problems
(human and animal) including case- and event-based
surveillance and response and risk communication in
line with IHR
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CPI-WHE-WHO/AFRO
 IDSR Core Functions and Health
Systems levels
Core functions
IDSR is a Comprehensive,
evidence-based strategy for
Identify strengthening national public
health surveillance and response
Report
Implementation Levels systems
Analyse
1. Community IDSR is Primarily used to conduct
Investigate surveillance, outbreak investigation
2. Health facility and response for common priority
Prepare
diseases and events
3. District, region or
Respond province
Communicate
4. National level
Evaluate

CPI-WHE-WHO/AFRO
 International Health Regulations (2005)

• In 2005, the resolutions WHA58.3 adopted IHR

(2005)
• IHR (2005) entered into force on 15 June 2007
in accordance with Article 59, replacing IHR
(1969)
• IHR (2005) is legally binding for WHO 194
Member States
 Includes all 47 WHO Member States in the
African region

CPI-WHE-WHO/AFRO
 Purpose and Scope of IHR (2005)

To prevent, protect against, control and provide

public health response to the international
spread of disease in ways that are commensurate
with and restricted to public health risks, and
which avoid unnecessary interference with
international traffic
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CPI-WHE-WHO/AFRO
 Implementing IHR through IDSR

Synergy between IDSR and IHR

IDSR will serve as a IHR will serve as the driving
vehicle for IHR force for IDSR
 Decision instrument (Annex 2)
4 diseases that shall be notified polio
(wild-type polio virus), smallpox, human
influenza new subtype, SARS.

Disease that shall always lead to utilization of

the algorithm: cholera, pneumonic plague,
yellow fever, VHF (Ebola, Lassa, Marburg),
West Nile Fever (WNF), others….

Q1: public health impact serious?

Q2: unusual or unexpected?
Q3: risk of international spread?
Q4: risk of travel/trade restriction?

Insufficient information: reassess

State parties that answer “Yes” to the question whether the event meets any two of
the four criteria above shall notify WHO according to article 6 of the IHR
 Principles of a new IHR Monitoring and Evaluation
Framework (IHR MEF)

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CPI-WHE-WHO/AFRO
Roles and Responsibilities of various actors in IDSR

Turn to Annex G of the 3rd Edition IDSR TG for the roles of the
following in IDSR:
1. Community health worker
2. Health Facility staff and Point of Entry
3. Surveillance Officer at district level
4. District Health Management Team
5. Political Leaders at district level
6. Regional or Provincial Health Management Team
7. Ministry of health
8. WHO and other partners

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Title of the Presentation
 Other IDSR Linkages

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CPI-WHE-WHO/AFRO
 IDSR in the context of One Health-1

• One Health approach addresses public health events

arising at the intersection of:
 human, animal (domestic and wildlife), and
environmental interface
 Humans and animals share the same eco-system

• One Health approach is intrinsic to and

strongly reinforced by WHO’s IHR and the IDSR
strategy
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CPI-WHE-WHO/AFRO
 IDSR in the context of One Health-2

• Animal and human health workers as well as other

relevant partners should be engaged at various levels
to be information sources for IDSR:

 To facilitate information sharing and joint rapid

response activities

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CPI-WHE-WHO/AFRO
 IDSR and Disaster Risk Management (DRM)
• DRM is a systematic process of using administrative and
organizational directives, operational skills and capacities to
implement strategies, policies and improved coping capacities
in order to lessen the adverse impact of hazards and the
possibility of disaster
• IDSR is a tool for DRM:
 Provides early warning information, for risk assessment and
risk reduction
 Assists in identification of hazards, assessment and
monitoring of disaster risks

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CPI-WHE-WHO/AFRO
 IDSR and Cross-Border Surveillance
• Countries in collaboration with WHO to establish:
 Cross-border surveillance and response framework with
neighbouring countries
 Procedures for information sharing within the framework of
IDSR
 Procedures for notification of detected Outbreaks to
neighbouring cross border areas and districts
 Develop and organize simulation exercises with cross border
district teams
 Organize regular cross border meetings
• Note: Strong Political Leadership required

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CPI-WHE-WHO/AFRO
 IDSR and Points of Entry (PoE)

• IHR 2005 calls for strengthening of national capacity for

surveillance and control, including PoE:
• i.e. Ports, Airports and Ground crossings
• Border health activities should be sustainable and aligned with
other surveillance activities under IDSR
• All designated PoE must have capacities for Surveillance and
Effective Public Health Response System in line with existing
IDSR at respective regions/province and districts

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CPI-WHE-WHO/AFRO
 Electronic IDSR (eIDSR)

• eIDSR is the application of electronic tools to the principles of

IDSR to facilitate prevention, prediction, detection, reporting
and response
• It is based on standardized interoperable and interconnected
information systems administered within the national context
• It is core in achievement of IHR (2005) requirements by
countries
• Reduce manual data entry that is prone to errors

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CPI-WHE-WHO/AFRO
 What are the priority diseases, conditions
and events for IDSR?

Refer to Introduction Section, subsection 1.15,

Table 1 of the 3rd Edition IDSR TGs Booklet One
for the priority diseases, conditions and events

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CPI-WHE-WHO/AFRO
 Priority diseases,
conditions and
events for
Integrated Disease
Surveillance and
Response in Sierra
Leone - 2020

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CPI-WHE-WHO/AFRO
 Practice Exercise 1
• Use information in the Introduction Section of the 3rd Edition
IDSR Technical Guidelines
• Answer Exercise 1 in your participants guide page 27
 Fill in the blank boxes with the appropriate terms from
the list provided:
o Prepare
o Respond
o Report
o Investigate and Confirm
o Communicate risk and provide feedback

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CPI-WHE-WHO/AFRO
 Practice Exercise 1
Figure 2 below is an incomplete flow diagram of an epidemic cycle.

Instructions: Use information in the Introduction Section of the 3rd Edition

IDSR Technical Guidelines to fill in the blank boxes with appropriate terms
from the following list:

Investig
ate and Report
Confirm

Plan
Communicate
risk and provide implement
feedback

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CPI-WHE-WHO/AFRO
 Introduction Sub-Module C: Community-
Based Surveillance

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CPI-WHE-WHO/AFRO
 What is Community-Based Surveillance?

• Community-based surveillance (CBS) is defined as a

surveillance system that collects community-based
health information and the entire community
population is under surveillance, and not simply a
segment of the community

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CPI-WHE-WHO/AFRO
 Role of community members in public health
surveillance and response
1. Provide early warning or alerts during the pre-epidemic
period
2. Report alerts and information on unusual public health
events in the community to the nearest health facility.
3. Support in active case detection and response during the
epidemic including contact tracing, community mobilization
& sensitization
4. Providing a forum for feedback to the community on
outbreak or event assessment

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CPI-WHE-WHO/AFRO
 Establishing community-based surveillance and
response system
Who is responsible?
• The catchment health facility or Sub-district Head/Manager
with support from the district, region/province and national
What is their role?
1. Develop CBS structures
2. Define the selection criteria for CBS focal persons
3. Draw terms of reference
4. Define roles and responsibilities of the CBS focal persons
5. Coordinate, supervise and monitor all CBS activities
implemented by the focal person

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 Steps for establishing community-based
surveillance and response system-1
• Step 1: Engage all stakeholders
• Step 2: Define the sources of information about health events
in the community
• Step 3: Identify community-based surveillance (CBS) focal
persons
• Step 4: Compile list of priority diseases, condition and
events/alerts for CBS
• Step 5: Develop simple case definition for the priority
diseases, condition and events

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CPI-WHE-WHO/AFRO
 Steps for establishing community-based
surveillance and response system-2
• Step 6: Develop and Disseminate data collection and reporting
tools
• Step 7: Define methods of reporting
• Step 8: Train all key actors in the CBS system
• Step 9: Develop risk communication and social mobilization
structures
• Step 10: Define methods for monitoring, supervision and
evaluation

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CPI-WHE-WHO/AFRO
 Procedure for CBS Focal person selection

Who is responsible:
• District and sub-district health team should work
with community leaders to identify members of the
community to be selected as CBS Focal persons
Who is Eligible to be CBS Focal Person:
• Any community member acceptable by the
community can be a CBS focal person
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CPI-WHE-WHO/AFRO
 CBS Focal person selection criteria-1

1. Hard working and committed to reporting

2. Resident in the community
3. Well known, trusted and respected member of the
community
4. Have the community’s welfare at heart
5. Accepted by the community so as to be able to
communicate with inhabitants

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CPI-WHE-WHO/AFRO
 CBS Focal person selection criteria-2
6. Be literate enough to record events/data on the register
provided
7. Selected irrespective of Gender
8. Be recognized by all identified groups where ethnic and
religious differences exist

NB: Once selected, the CBS focal person should be trained in

their roles and responsibilities

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CPI-WHE-WHO/AFRO
 Roles and Responsibilities of a community
based surveillance focal person-1
1. Use community case definitions to identify, record
priority diseases/conditions/events
2. Report to nearest health facility/sub-district
immediately within 24 hours
3. Support health workers during case/outbreak
investigation and contact tracing
4. Conduct household visits on a regular basis
5. Meet with key informants on a regular basis

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 Roles and Responsibilities of a community
based surveillance focal person-2
6. Sensitization of the community on priority diseases,
conditions, and unusual events

7. Mobilize local authorities and community members to

support response activities

8. Attend local ceremonies and events and follow up on

anything unusual

9. Participating in risk mapping of potential hazards

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 Example of CBS activities
• CBS focal person hears of several cases of acute watery
diarrhoea with vomiting in the community. The CBS focal
person suspects cholera and reports the rumour to the local
health facility and to the district level heath officer by text
messaging.
• Members of the public health emergency rapid response
team (PHERRT) travelled to the community to verify and
investigate the possible outbreak, and, based on the
investigation results, implemented control and prevention
measures. The outbreak is quickly contained thanks to the
early warning from the community-based surveillance focal
person

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 IDSR community case definitions for use at the
community level

• Inform all members of the community the priority

diseases/conditions/events under surveillance in your
area
• Use key signs and symptoms of case definitions which
have simple language and easier to understand
• Turn to Section 1, Annex 1B of the 3rd Edition IDSR
Technical Guidelines Booklet Two for Sample
community case definitions

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 How to report diseases, conditions and
events from the community levels

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 Sources of information for CBS-1

• Community based health workers and Volunteers

• Traditional birth attendants, school teachers, pharmacists
/medicine sellers
• Staff at private clinics
• Community animal health workers
• Community Based Organizations (CBOs)
• Community leaders: traditional/youth/religious

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 Sources of information for CBS-2

• Media such as radio & newspapers, social media

• Traditional medicine practitioners e.g. traditional
healers/herbalist and shrine keepers
• Home Visits
• Social gathering places such as churches, mosque,
markets, school etc.

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 What and how to report in CBS-1
What to report immediately/within 24hours:
• Anyone with onset of an illness meeting any of the IDSR
community case definitions in the catchment area
OR
• Any sudden death, if the catchment area is experiencing an
ongoing public health event of the IDSR priority conditions
OR
• Any unusual public health event e.g. unexplained cluster of
similar severe illnesses within one week, high absenteeism at
school

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CPI-WHE-WHO/AFRO
 What and how to report in CBS-2

How to report:
• Report to the CBS Supervisor or Surveillance officer or
nearest Health facility Manager
• By phone call/test message/hand delivery/using
vehicle/walking to nearest health facility
• Record in community alert forms

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 Linkage between Facility-based
surveillance and CBS
• HF/sub-district health team with DHMT support should verify all
reports from CBS Focal person

• If it is confirmed as TRUE;

 HF surveillance focal person captures it on the IDSR

Weekly/monthly summary reporting form of the respective
HF catchment area

 This is then reported to district; to region and to national

authorities weekly and monthly

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Verification and Investigation of CBS Events
 Community alert reporting form
Community alert reporting form

[Send this form immediately to your supervisor or nearby health facility]

1. Name of CBS focal person reporting:____________________________

2. Telephone number:_____________________Community___________________District_________________

3. Date reporting (day, month, year)__ __/__ __/__ __ __ __

4. Type of illness/Condition/Event/Signal (please describe): ___________________________________

5. When did this happen (Date: Day/Month/Year); Time __ __/__ __/__ __ __ __

6. Date/time this was detected (Date: Day/Month/Year); Time: __ __/__ __/__ __ __ __

7. Where did this happen?

(Location: community, ward/sub-district, district)

8. How many people have been affected?

9. Has anyone died? If yes, how many

10. Are there sick or dead animals involved?

11. Is the event ongoing as at the time of this report?

12. What action has been taken?

Community-Based Surveillance (CBS) Suspected Diseases
and Public Health Events Monthly Log Sheet
Community-Based Surveillance Suspected Diseases and Public Health Events Monthly Log Sheet

District______________________________________Ward/Subdistrict______________________________

Community:_________________________________________Month__________________ Year__________
Serial Type of illness/ When did this Where did How many How what
Number Condition/Event/Alert happen this happen have been many action was
affected died taken
(DD/MM/YYY) (Community,
District)
 Sample pictorial CBS register/note book

Cases/Conditions/Events/Alert to be
Code Image
reported

Insert pictures/images describing the

Case/Conditions/Events/Alerts to
01 Any person with headache and stiff neck
assist in detection at the community
level

02 Any person with fever and rash

Two or more persons presenting with similar

03 signs/symptoms from the same community, school, or
workplace within one week

A cluster of unexplained deaths of animals within one

04
week

05 Any person presenting with new or rare signs/symptoms

 Sample Verification Tool for Unusual Health
Events/Alerts
Two or more persons presenting with similar severe illnesses in the same community
within one week
• There is only one person
False if...
True if...
presenting with illness
• The persons present with
dissimilar signs and symptoms
• There is no temporal
association, and >1 week
separates the patients’ illness
• The persons presenting with
similar symptoms reside in
different communities that are
physically well-separated
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CPI-WHE-WHO/AFRO
• There are two or more persons
presenting with similar signs
and symptoms who live or work
in the same community
• The ill persons had an
opportunity for exposure or
close contact with one another
• The persons’ illness requires
hospitalization
• One or more persons has died
• There is a common source of
exposure
Steps for investigating and confirming a suspected public
health event reported by CBS Focal Person-1

1. Form a field response team: HF/ Sub-district team

2. Verify the CBS focal person’s information
3. HF/ sub-district team gathers further information
about the suspected case/public health event
4. Use verification tool to access; If TRUE, Notify DHMT
5. Further investigation by the District PHERRT

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Steps for investigating and confirming a suspected public
health event reported by CBS Focal Person-2

6. DHMT Notify Region/Province and National

7. Carry out the recommended response as per the
outbreak investigation findings
8. The CBS Focal Person supports the Sub-district and
District Teams to carry out the response activities

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 Providing feedback to the community–1

• Following verification and confirmation of a public

health event, the District PHERRT should:
 Liaise with regional/provincial and national level
authorities
 Seek guidance on giving feedback to the
community
 Follow the directions and key messages provided
by national authority

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 Providing feedback to the community–2

• CBS focal persons should work within the field response

team to disseminate preventive messages through:
 Regular Community briefings
 Identified local channels
 Regular meeting with local stakeholders
 Door-to-door campaigns to reach every household

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 Monitoring, supervision and evaluation of CBS
implementation-1

• Assess whether CBS activities are on track:

 Role of CBS Focal Persons activities are well
described
 A CBS supervision plan exists
 A checklist exists and used to monitor how well
the CBS focal persons agreed activities

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 Monitoring, supervision and evaluation of CBS
implementation-2

• Evaluate the timeliness and completeness of the

community-based surveillance reporting and record
keeping functions:
 Assess the CBS detection and notification
procedures for suspected public health events
 Identify the problems and take remedial action

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 Monitoring, supervision and evaluation of CBS
implementation-3

• Evaluate CBS implementation:

 All activities for implementation by CBS should
be coordinated by:
o Surveillance officer or
o Health facility manager in his or her locality

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 CBS Supervision -1

• The health facility/sub-district team conducts

supervisory visits to the CBS Focal Persons at least once
in month
• During supervisory visit:
 Feedback is given to CBS focal points
 On-the-job training is provided as needed if a
problem is identified

CPI-WHE-WHO/AFRO
 CBS Supervision-2

• During supervisory visit:

 Follow-up on requests for assistance is provided
 Supervisory plans for improvement of surveillance
and response are updated
 Successful activities are recorded and
encouragement for their continuation provided
 Feasible solutions are provided for identified
problems

CPI-WHE-WHO/AFRO
 Practice Exercises

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 Practice Exercises-1/2

Instructions:
• Break into 3 small groups of a minimum of 5 people
• Each group should select a leader and a rapporteur
 The leader moderates the group discussions
 Rapporteur documents the agreed answers by
the group

CPI-WHE-WHO/AFRO
 Practice Exercises-2/2

Instructions:
• Each group assigned one exercise (exercises 2, 3 and 4 )
 Turn to your participants guide Introduction Module, pages
40 to 45
 Each group has 30 min to read, discuss and answer all
questions to the assigned exercise
 Group leaders present answers during plenary discussions:
• 5 min presentation; 5 min discussion

CPI-WHE-WHO/AFRO
 Summary- Introduction Module-1

• IDSR is a strategy for coordinating and integrating

surveillance activities at all levels
• Event-based surveillance is based on screening of all
available information to detect any event happening in
the community
• Animal and human health workers should be engaged at
all levels to generate information for IDSR to facilitate
information sharing and joint rapid response activities

CPI-WHE-WHO/AFRO
 Summary- Introduction Module-2

• IDSR is an important tool in the DRM

• Effective CBS system is key to early detection and response to
public events and emergencies
• CBS focal person(s) should report within 24HRS to the nearest
HF/sub-districts suspected disease/conditions/events
• Health facility/sub-district health team should verify all reports
by using verification tools with support from the district health
team

CPI-WHE-WHO/AFRO
 Thank you

CPI-WHE-WHO/AFRO