How can we improve global infectious disease surveillance and prevent the next outbreak?

Originally published here

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Despite a significant amount of progress in the past decade, global infectious disease surveillance still often falters, as in the case of the emerging novel coronavirus that has killed at least 17 people in Saudi Arabia. This article argues that we must continuously re-evaluate global infectious disease surveillance systems. It takes stock of problems in various countries’ infectious disease surveillance systems and offers recommendations for how to improve surveillance and ensure more rapid reporting. Chief among the recommendations are strategies for reducing fragmentation in global surveillance systems and methods for making these systems less disease-specific. Suggestions are also offered for ways to improve infectious disease surveillance strategies in resource-limited settings.

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In light of recent panic over the detection of a novel influenza A virus (H7N9), an editorial in The New England Journal of Medicine warned that “we cannot rest our guard” [1]. The authors commended Chinese scientists for rapid identification and reporting of the new virus [1]. At the same time, by February 15, 2013, a novel coronavirus, occurring eerily exactly a decade after severe acute respiratory syndrome (SARS), had killed 6 of the 12 people infected to that point [2]. Yet 6 months after the first report of this novel coronavirus, not nearly enough is known about the illness. Scientists feel certain that there are more cases, some perhaps so mild that the infected individuals are not seeking care. Human-to-human transmission of the newly characterized coronavirus probably occurs, but little is known about the mechanism or efficiency of infection [3]. Part of the problem is that affected countries have not offered the appropriate amount of information for full epidemiological analyses to be conducted. Saudi Arabia has reported 9 novel coronavirus infections to the World Health Organization (WHO), but information is still missing about patient age, sex, residence, and circumstances surrounding infection [3]. Although SARS was ultimately largely contained, China’s initial reluctance to report the outbreak is another well-known example of resistance to reporting disease outbreak information [4]. China also did not report a 2003 case of H5N1 until 2006 [5].

‘Infectious disease surveillance’, an important component of any public health system, refers to a variety of strategies, including monitoring a disease over time and reporting of clinical cases or disease clusters. Some surveillance systems depend on clinical observation, some on laboratory tests, others on computer-based searches of public health records or individual patients, and still others on mathematical modeling and prediction [6]. A decade after the SARS epidemic, it seems apt to take stock of how much better prepared we are now to deal with emerging pathogens. The evidence is mixed. On the one hand, we have come very far. Infectious disease surveillance has improved, and scientific advances make it easier to sequence the genome of an emergent pathogen much more rapidly. The SARS experience also induced the introduction in 2005 of new international rules to report novel diseases [6]. Electronic and communication networks have expanded, and the WHO has even begun to provide information on emerging outbreaks in real time on their website. The WHO has also developed a wider network, the Global Outbreak Alert and Response Network (GOARN), aggregating information from a wider variety of sources, and has revised the International Health Regulations to include more infectious diseases [7]. At the same time, our experience with the novel coronavirus shows that there is still a ways to go in improving our global response to emerging infectious disease threats. Many countries still lack the infrastructure to detect and report a disease early on. After the first case of novel coronavirus in Saudi Arabia, it took 3 months for information about the illness to emerge in the global arena [3].

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What are some of the problems with the current operation of local and international infectious disease surveillance systems? One obvious problem is the reluctance of local governments to report diseases for fear of negative repercussions on tourism and trade and general feelings of embarrassment. On a more structural level, systems of disease reporting and surveillance are extremely fragmented, since surveillance systems tend to be reactive and disease-specific [5]. For example, in the USA, surveillance systems are decentralized, operating under local, state-controlled reporting regulations, with information then forwarded to the Centers for Disease Control and Prevention (CDC). Even in countries with centralized reporting procedures, there may not always be a straightforward link between centralized control and effectiveness of surveillance [5]. Reporting relationships between local entities and the capitals of these countries may often be lacking. For example, this was certainly the case in China during the SARS outbreak: although China has strong centralized political control, communication between localities and the capital were observed to be very weak during the SARS epidemic [5]. This lack of communication is not always the case, but it does show that centralized control does not always mean more effective surveillance.

Competition for public health resources can sometimes render funds for infectious disease control inadequate [5]. We also have a surprising dearth of knowledge when it comes to epidemiological mapping of infectious disease threats. It is difficult to gauge the seriousness of emerging disease threats if we do not have a full understanding of their geographical spread [8]. Surveillance systems that are too disease-specific can also miss the early warning signs of emergent infectious disease threats [9]. They are also often passive, picking up on new diseases in a haphazard manner, and developed according to the local organization of public health systems, making international recognition much more difficult [5].

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What can be done to improve surveillance systems and aid in the prevention of emerging epidemic threats? Evidence suggests that outbreaks in developing countries are being reported more swiftly, especially informally by individual citizens. As a result, some experts suggest that focusing on ways to improve infectious disease reporting via cell phones, whether through SMS or smart phones, could be an incredibly useful venture [10]. The development of more systems similar to HealthMap that aggregate and organize informal web-based modes of infectious disease reporting, such as online news sources and discussion sites, could also be incredibly useful [11]. These systems must be made more user-friendly to individuals living in developing countries in particular, where a significant infectious disease burden exists. Strategies may include developing interfaces in additional languages and implementing mobile phone alerts [11].

Coordinating global reporting systems to better aggregate and share data is essential, as is training individual citizens to recognize and report outbreaks [5]. Just as community health workers and clinicians have been trained to detect outbreaks, so should individual citizens be educated about the signs of emerging infections and the protocol for reporting. For example, community educators could teach village communities in developing countries about the warning signs of emerging infections or about symptoms of common infectious threats in the region. Village citizens would also be taught about how to report infectious disease threats to the appropriate authorities, always being encouraged to over-report rather than under-report. In more developed countries, where people have easy access to the internet and technologies such as iPads and iPhones, government agencies could even develop applications that function as checklists for infectious disease threats and facilitate the process of reporting. For example, the US CDC recently developed an iPad app called “Solve the Outbreak” that, although a game, allows people to function as infectious disease epidemiologists; it is also intended to teach people about the warning signs of emerging infectious disease threats and inform them about the steps to take to report these threats. Additionally, explaining to policymakers why disease surveillance should be a priority is vital [5]. Seizing upon the right timing is important in this process, for instance in the wake of an epidemic disease threat such as novel coronavirus, when the problem of infectious disease outbreaks is already on the minds of high-level decision-makers. Clarifying that proper surveillance efforts are cost-effective is also essential in convincing policymakers of the importance of strengthening these systems.

Directing disease surveillance efforts to the right locations is also crucial. At the moment, most disease surveillance efforts focus on more developed nations, but threats of emerging infectious diseases may be most significant in places such as Africa, Latin America, and Southeast Asia because of population growth and increased antibiotic use [12]. Encouraging more countries to adopt the same infectious disease surveillance systems, such as the ProMED-mail system, to complement their own strategies, and making subscriptions to such services easy and affordable, could help reduce fragmentation of global infectious disease surveillance techniques [13]. International veterinary agencies that monitor global animal safety and disease need to be better connected to agencies such as the WHO that focus on human disease in order to help control infectious diseases with animal reservoirs [14]. At the moment, the operations of these types of agencies are wholly separate from each other, demonstrating another key source of fragmentation in global infectious disease surveillance systems.

Quality infectious disease surveillance is lacking especially in developing countries, where the infectious disease threat is often greatest. One way to close the gap in infectious disease surveillance is to better disperse technological advancements such as rapid diagnostic tools [15]. There is evidence demonstrating that rapid, affordable, inexpensive diagnostic tools can greatly contribute to quicker and more effective infectious disease surveillance [6]. Diagnostic tests that differentiate between different strains and organisms and point-of-care diagnostic tests are also needed [16]. Steps should be taken to help more local clinics in developing countries connect to the internet and thereby have the opportunity to take part in an important form of emerging infectious disease reporting. Web-based forms to report diseases via cell phone should also be provided in developing countries, since cell phones are widely available even in low-income villages [5]. International aid and public health agencies need to create realistic funding plans to help improve healthcare infrastructure in developing countries, including distributing resources needed to develop and distribute rapid diagnostic tools and training local health workers to use them [6].

Much research on the effectiveness of certain kinds of surveillance still needs to be done. More reports about the timeliness of responses to infectious disease outbreaks should be implemented. The best way to measure timeliness is to calculate the median delay between the date of disease occurrence (as identified by disease onset date, diagnosis date, or laboratory result date) and the date the public health system was notified for particular infectious disease threats. Evaluations of surveillance systems should more regularly take timeliness of response into account as a key measure of further needed progress [17]. Similarly, comparative cost-effectiveness analyses need to be conducted on various surveillance systems to have a better understanding of which forms of surveillance and reporting are most financially efficient. Clear measures of effectiveness and cost-effectiveness of various, existing infectious disease surveillance methodologies are desperately needed [6]. One 2010 PLoS One study of the Integrated Disease Surveillance and Response (IDSR) system in Burkina Faso provides a good model of how to measure this [18]. The authors of this study collected epidemiological data on the number of meningococcal meningitis cases in Burkina Faso before and after the implementation of the IDSR. They found a significant decline in cases, and although they noted this decline could be the result of other factors, they hypothesized that the decreases were primarily the result of the novel surveillance system, largely because the authors did not find statistically significant evidence for the existence of other factors to explain the decrease, such as an increase in vaccine imports. They then estimated costs per case, costs per death, and costs per sequelae prevented and concluded that the implementation of the surveillance system was cost-effective. More studies such as this one could be conducted in other regions with other infectious diseases to measure cost-effectiveness.

Although infectious disease surveillance has been vastly improved in the decade since SARS, there is still plenty of room for further progress. Even as China is to be commended for the rapid response to H7N9, we cannot rest easy. We must still continuously re-evaluate global systems of infectious disease surveillance and continue to improve them.

Declaration of interest: No special funding has been received for this article. The author declares no conflicts of interest.

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