Polio Eradication Initiative: Contribution to improved communicable diseases surveillance in WHO African region

IntroductionSince the launch of the Global Polio Eradication Initiative (GPEI) in 1988, there has been a tremendous progress in the reduction of cases of poliomyelitis. The world is on the verge of achieving global polio eradication and in May 2013, the 66th World Health Assembly endorsed the Polio Eradication and Endgame Strategic Plan (PEESP) 2013–2018. The plan provides a timeline for the completion of the GPEI by eliminating all paralytic polio due to both wild and vaccine-related polioviruses.MethodsWe reviewed how GPEI supported communicable disease surveillance in seven of the eight countries that were documented as part of World Health Organization African Region best practices documentation. Data from WHO African region was also reviewed to analyze the performance of measles cases based surveillance.ResultsAll 7 countries (100%) which responded had integrated communicable diseases surveillance core functions with AFP surveillance. The difference is on the number of diseases included based on epidemiology of diseases in a particular country. The results showed that the polio eradication infrastructure has supported and improved the implementation of surveillance of other priority communicable diseases under integrated diseases surveillance and response strategy.ConclusionAs we approach polio eradication, polio-eradication initiative staff, financial resources, and infrastructure can be used as one strategy to build IDSR in Africa. As we are now focusing on measles and rubella elimination by the year 2020, other disease-specific programs having similar goals of eradicating and eliminating diseases like malaria, might consider investing in general infectious disease surveillance following the polio example.     

A Mobile App and Dashboard for Early Detection of Infectious Disease Outbreaks: Development Study

BackgroundOutbreaks of infectious diseases pose great risks, including hospitalization and death, to public health. Therefore, improving the management of outbreaks is important for preventing widespread infection and mitigating associated risks. Mobile health technology provides new capabilities that can help better capture, monitor, and manage infectious diseases, including the ability to quickly identify potential outbreaks.ObjectiveThis study aims to develop a new infectious disease surveillance (IDS) system comprising a mobile app for accurate data capturing and dashboard for better health care planning and decision making.MethodsWe developed the IDS system using a 2-pronged approach: a literature review on available and similar disease surveillance systems to understand the fundamental requirements and face-to-face interviews to collect specific user requirements from the local public health unit team at the Nepean Hospital, Nepean Blue Mountains Local Health District, New South Wales, Australia.ResultsWe identified 3 fundamental requirements when designing an electronic IDS system, which are the ability to capture and report outbreak data accurately, completely, and in a timely fashion. We then developed our IDS system based on the workflow, scope, and specific requirements of the public health unit team. We also produced detailed design and requirement guidelines. In our system, the outbreak data are captured and sent from anywhere using a mobile device or a desktop PC (web interface). The data are processed using a client-server architecture and, therefore, can be analyzed in real time. Our dashboard is designed to provide a daily, weekly, monthly, and historical summary of outbreak information, which can be potentially used to develop a future intervention plan. Specific information about certain outbreaks can also be visualized interactively to understand the unique characteristics of emerging infectious diseases.ConclusionsWe demonstrated the design and development of our IDS system. We suggest that the use of a mobile app and dashboard will simplify the overall data collection, reporting, and analysis processes, thereby improving the public health responses and providing accurate registration of outbreak information. Accurate data reporting and collection are a major step forward in creating a better intervention plan for future outbreaks of infectious diseases.     

Improving Detection of Disease Re-emergence Using a Web-Based Tool (RED Alert): Design and Case Analysis Study

BackgroundCurrently, the identification of infectious disease re-emergence is performed without describing specific quantitative criteria that can be used to identify re-emergence events consistently. This practice may lead to ineffective mitigation. In addition, identification of factors contributing to local disease re-emergence and assessment of global disease re-emergence require access to data about disease incidence and a large number of factors at the local level for the entire world. This paper presents Re-emerging Disease Alert (RED Alert), a web-based tool designed to help public health officials detect and understand infectious disease re-emergence.ObjectiveOur objective is to bring together a variety of disease-related data and analytics needed to help public health analysts answer the following 3 primary questions for detecting and understanding disease re-emergence: Is there a potential disease re-emergence at the local (country) level? What are the potential contributing factors for this re-emergence? Is there a potential for global re-emergence?MethodsWe collected and cleaned disease-related data (eg, case counts, vaccination rates, and indicators related to disease transmission) from several data sources including the World Health Organization (WHO), Pan American Health Organization (PAHO), World Bank, and Gideon. We combined these data with machine learning and visual analytics into a tool called RED Alert to detect re-emergence for the following 4 diseases: measles, cholera, dengue, and yellow fever. We evaluated the performance of the machine learning models for re-emergence detection and reviewed the output of the tool through a number of case studies.ResultsOur supervised learning models were able to identify 82%-90% of the local re-emergence events, although with 18%-31% (except 46% for dengue) false positives. This is consistent with our goal of identifying all possible re-emergences while allowing some false positives. The review of the web-based tool through case studies showed that local re-emergence detection was possible and that the tool provided actionable information about potential factors contributing to the local disease re-emergence and trends in global disease re-emergence.ConclusionsTo the best of our knowledge, this is the first tool that focuses specifically on disease re-emergence and addresses the important challenges mentioned above.     

A Study on the Relapse Rate of Tuberculosis and Related Factors in Korea Using Nationwide Tuberculosis Notification Data

ObjectivesFrom the perspective of public health, tuberculosis (TB) remains an important issue that threatens health. Korea is an intermediate burden country with a TB incidence of 97/100,000 individuals. Among many TB control measures, a relapse rate of TB is one indicator that can be used to indirectly assess the level of TB control in countries and in communities. Relapse TB has an approximately 12% yearly incidence in Korea. This study aims to estimate the relapse rate of TB and to investigate the associated factors by using nationwide TB notification data in Korea.MethodsThe nationwide TB notification data in 2005 was used with the exclusion criteria of duplicated reporting, foreign-born patients, outcome–died, and outcome–diagnosis changed. The data were double-checked as to whether they were reported again during 2006–2010 and the estimated relapse rate of TB. Associated factors were analyzed by multivariate logistic regression with the variables of age, sex, registration type, results of sputum smear test, medication, and outcome of treatment.ResultsAmong 45,434 TB patients in 2005, 4,371 patients were again reported as TB patients from 2006 to 2010. Five hundred and sixty-four patients were reported more than twice and the cumulative number of relapses was 5,072 cases. The 5-year relapse rate was estimated as 9.62%. The relapse rate decreased yearly: 4.8% in 2006, 2.4% in 2007, 1.6% in 2008, 1.4% in 2009, and 1.0% in 2010. Age, sex, registration type, tuberculosis type, and medication were independently associated with a relapse of TB. In the multivariate logistic regression analysis, the following factors were related: male sex, 40–49 years old; registration type, relapse, treatment after failure, treatment after default, transfer in, and other, the sputum smear-positive pulmonary TB, and medications (including individuals taking 2–5 drugs).ConclusionThis study has estimated a 5-year relapse rate of TB in Korea that is slightly lower than the rate of relapse TB in the annual reports. This study could be conducted and cross-checked with data from the National Health Insurance in the future.     

Beyond traditional surveillance: applying syndromic surveillance to developing settings – opportunities and challenges

Background  

All countries need effective disease surveillance systems for early detection of outbreaks. The revised International Health Regulations [IHR], which entered into force for all 194 World Health Organization member states in 2007, have expanded traditional infectious disease notification to include surveillance for public health events of potential international importance, even if the causative agent is not yet known. However, there are no clearly established guidelines for how countries should conduct this surveillance, which types of emerging disease syndromes should be reported, nor any means for enforcement.     

Unbalanced Risk of Pulmonary Tuberculosis in China at the Subnational Scale: Spatiotemporal Analysis

BackgroundChina has one of the highest tuberculosis (TB) burdens in the world. However, the unbalanced spatial and temporal trends of TB risk at a fine level remain unclear.ObjectiveWe aimed to investigate the unbalanced risks of pulmonary tuberculosis (PTB) at different levels and how they evolved from both temporal and spatial aspects using PTB notification data from 2851 counties over a decade in China.MethodsCounty-level notified PTB case data were collected from 2009 to 2018 in mainland China. A Bayesian hierarchical model was constructed to analyze the unbalanced spatiotemporal patterns of PTB notification rates during this period at subnational scales. The Gini coefficient was calculated to assess the inequality of the relative risk (RR) of PTB across counties.ResultsFrom 2009 to 2018, the number of notified PTB cases in mainland China decreased from 946,086 to 747,700. The average number of PTB cases in counties was 301 (SD 26) and the overall average notification rate was 60 (SD 6) per 100,000 people. There were obvious regional differences in the RRs for PTB (Gini coefficient 0.32, 95% CI 0.31-0.33). Xinjiang had the highest PTB notification rate, with a multiyear average of 155/100,000 (RR 2.3, 95% CI 1.6-2.8; P<.001), followed by Guizhou (117/100,000; RR 1.8, 95% CI 1.3-1.9; P<.001) and Tibet (108/100,000; RR 1.7, 95% CI 1.3-2.1; P<.001). The RR for PTB showed a steady downward trend. Gansu (local trend [LT] 0.95, 95% CI 0.93-0.96; P<.001) and Shanxi (LT 0.94, 95% CI 0.92-0.96; P<.001) experienced the fastest declines. However, the RRs for PTB in the western region (such as counties in Xinjiang, Guizhou, and Tibet) were significantly higher than those in the eastern and central regions (P<.001), and the decline rate of the RR for PTB was lower than the overall level (P<.001).ConclusionsPTB risk showed significant regional inequality among counties in China, and western China presented a high plateau of disease burden. Improvements in economic and medical service levels are required to boost PTB case detection and eventually reduce PTB risk in the whole country.     

Health systems and the implementation of disease programmes: Case studies from South Africa

Abstract

This paper analyses the transfer and implementation of two internationally formulated infectious disease strategies in South Africa, namely, directly observed therapy (DOTS) for TB and syndromic management (SM) for sexually transmitted infections (STIs). Using the tools of policy analysis, this paper seeks to draw conclusions from contrasting experiences with the two strategies. DOTS and SM differ with respect to styles of engagement by World Health Organization (WHO), the international agency promoting the ideas, in the following ways: continuity and networking between policy makers, practitioners and researchers nationally; and approaches to sub-national implementation. We show how these factors may have been important to national uptake, and conclude on the need for a context sensitive approach to policy transfer and a balance between bottom-up and top-down implementation strategies. These insights may have relevance for the current global wave of treatment programmes for HIV and other infectious diseases.     

The US National Tuberculosis Surveillance System: A Descriptive Assessment of the Completeness and Consistency of Data Reported from 2008 to 2012

Background

In 2009, the Tuberculosis (TB) Information Management System transitioned into the National TB Surveillance System to allow use of 4 different types of electronic reporting schemes: state-built, commercial, and 2 schemes developed by the Centers for Disease Control and Prevention. Simultaneously, the reporting form was revised to include additional data fields.

Objective

Describe data completeness for the years 2008-2012 and determine the impact of surveillance changes.

Methods

Data were categorized into subgroups and assessed for completeness (eg, the percentage of patients dead at diagnosis who had a date of death reported) and consistency (eg, the percentage of patients alive at diagnosis who erroneously had a date of death reported). Reporting jurisdictions were grouped to examine differences by reporting scheme.

Results

Each year less than 1% of reported cases had missing information for country of origin, race, or ethnicity. Patients reported as dead at diagnosis had death date (a new data field) missing for 3.6% in 2009 and 4.4% in 2012. From 2010 to 2012, 313 cases (1%) reported as alive at diagnosis had a death date and all of these were reported through state-built or commercial systems. The completeness of reporting for guardian country of birth for pediatric patients (a new data field) ranged from 84% in 2009 to 88.2% in 2011.

Conclusions

Despite major changes, completeness has remained high for most data elements in TB surveillance. However, some data fields introduced in 2009 remain incomplete; continued training is needed to improve national TB surveillance data.     

Social determinants and risk factors for tuberculosis in national surveillance systems in Europe

Setting: National tuberculosis programmes (NTPs) of the 53 Member States of the World Health Organization (WHO) European Region.Objectives: To identify the social determinants and underlying risk factors for tuberculosis (TB) as routinely monitored by NTPs and to identify those feasible and appropriate to be included in the annual reporting to the joint European Centre for Disease Prevention and Control (ECDC) WHO reporting platform.Design: A semi-structured questionnaire sent to 53 national TB surveillance correspondents.Results: A total of 47 countries submitted questionnaires; most of the countries collect a number of social determinants and risk factors that are not requested for reporting to the Joint ECDC-WHO Reporting Platform. Occupation/employment, homelessness, diabetes mellitus and use of alcohol are collected by the majority of countries, but without standardised definitions.Conclusions: Four social determinants/risk factors are already included in the national TB surveillance systems of the majority of countries and could be incorporated in the annual reporting to the Joint ECDC/WHO Reporting Platform. Standardised epidemiological case definitions need to be adopted.     

General practitioner notifications of gastroenteritis and food poisoning: cause for concern

BACKGROUND: Under the Public Health (Infectious Diseases) Regulations 1988, all doctors are required by law to notify suspected cases of specific infections and food poisoning. Doctors' propensity to notify is known to be low, and we sought to quantify this locally. METHODS: From July 2000 to June 2002, we conducted a baseline audit of notifications by Wakefield GPs of cases of suspected gastrointestinal infection or food poisoning. We repeated the audit during 2005-06, following a series of local interventions to improve notification. RESULTS: The baseline audit demonstrated considerable variation in reporting behaviour and timeliness of notification. Following the re-audit, we found that notification rates and timeliness had not improved, indeed they had deteriorated. CONCLUSION: We suggest that the current notification system is not working in respect of gastroenteritis and food poisoning, and should be either substantially revised or abandoned.     

Global Capacity for Emerging Infectious Disease Detection, 1996–2014

The speed with which disease outbreaks are recognized is critical for establishing effective control efforts. We evaluate global improvements in the timeliness of outbreak discovery and communication during 2010–2014 as a follow-up to a 2010 report. For all outbreaks reported by the World Health Organization’s Disease Outbreak News, we estimate the number of days from first symptoms until outbreak discovery and until first public communication. We report median discovery and communication delays overall, by region, and by Human Development Index (HDI) quartile. We use Cox proportional hazards regression to assess changes in these 2 outcomes over time, along with Loess curves for visualization. Improvement since 1996 was greatest in the Eastern Mediterranean and Western Pacific regions and in countries in the middle HDI quartiles. However, little progress has occurred since 2010. Further improvements in surveillance will likely require additional international collaboration with a focus on regions of low or unstable HDI.     

Adoption of revised dosage recommendations for childhood tuberculosis in countries with different childhood tuberculosis burdens

Background and objective:

In 2010, the World Health Organization (WHO) published revised dosage recommendations for the treatment of tuberculosis (TB) in children. The aim of the survey was to assess whether countries adopt these new dosage recommendations, as well as to identify challenges in the management and treatment of childhood TB. In addition, countries were asked to provide 2010 surveillance data on childhood TB.

Design:

A survey questionnaire was developed and broadly disseminated to National Tuberculosis Programmes or people with close links to them.

Results:

Among the 34 countries that responded to the survey, the proportion of total national TB caseload reported in children in 2010 ranged from 0.67% to 23.6%. The data on new cases reported to this survey varied from data provided to the WHO global TB database. Most countries had childhood TB guidelines in place, and half had adopted the new dosage recommendations. Countries reported a number of challenges related to the implementation of the new recommendations and general management of childhood TB.

Conclusions:

Despite the adoption of the new dosage recommendations, their implementation is complicated by the lack of appropriate fixed-dose combinations. In addition, accurate and consistent estimates of the global burden of childhood TB remained a major challenge. Technical assistance and support to countries is needed to improve childhood TB activities.     

Global public health surveillance under new international health regulations

The new International Health Regulations adopted by the World Health Assembly in May 2005 (IHR 2005) represents a major development in the use of international law for public health purposes. One of the most important aspects of IHR 2005 is the establishment of a global surveillance system for public health emergencies of international concern. This article assesses the surveillance system in IHR 2005 by applying well-established frameworks for evaluating public health surveillance. The assessment shows that IHR 2005 constitutes a major advance in global surveillance from what has prevailed in the past. Effectively implementing the IHR 2005 surveillance objectives requires surmounting technical, resource, governance, legal, and political obstacles. Although IHR 2005 contains some provisions that directly address these obstacles, active support by the World Health Organization and its member states is required to strengthen national and global surveillance capabilities.     

Capture–Recapture Method for Estimating Annual Incidence of Imported Dengue,France, 2007–2010

Imported dengue cases pose the public health risk for local circulation in European areas, especially southeast France, where the Aedes mosquito is established. Using a capture–recapture method with Chao’s estimator, we estimated the annual incidence of dengue fever and the completeness of existing mandatory notification and laboratory network surveillance systems. During 2007–2010, >8,300 cases with laboratory evidence of recent dengue infection were diagnosed. Of these cases, 4,500 occurred in 2010, coinciding with intense epidemics in the French West Indies. Over this 4-year period, 327 cases occurred in southeast France during the vector activity period. Of these, 234 cases occurred in 2010, most of them potentially viremic. Completeness of the mandatory notification and laboratory network systems were ≈10% and 40%, respectively, but higher in southeast areas during May–November (32% and 69%, respectively). Dengue surveillance systems in France provide complementary information that is essential to the implementation of control measures.     

Evaluation of the National Tuberculosis Surveillance System in Sana’a,Yemen, 2018: Observational Study

BackgroundTuberculosis remains a public problem that is considered one of the top causes of morbidity and mortality worldwide. The National Tuberculosis Control Program in Yemen was established in 1970 and included in the national health policy under the leadership of the Ministry of Public Health and Population to monitor tuberculosis control. The surveillance system must be evaluated periodically to produce recommendations for improving performance and usefulness.ObjectiveThis study aims to assess the usefulness and the performance of the tuberculosis surveillance system attributes and to identify the strengths and weaknesses of the system.MethodsA quantitative and qualitative evaluation of the national tuberculosis surveillance system was conducted using the Centers for Disease Control and Prevention’s updated guidelines. The study was carried out in 10 districts in Sana’a City. A total of 28 public health facilities providing tuberculosis services for the whole population in their assigned catchment areas were purposively selected. All participants were interviewed based on their involvement with key aspects of tuberculosis surveillance activities.ResultsThe tuberculosis surveillance system was found to have an average performance in usefulness (57/80, 71%), flexibility (30/40, 75%), acceptability (174/264, 66%), data quality (4/6, 67%), and positive predictive value (78/107, 73%), and poor performance in simplicity (863/1452, 59%) and stability (15%, 3/20). In addition, the system also had a good performance in sensitivity (78/81, 96%).ConclusionsThe tuberculosis surveillance system was found to be useful. The flexibility, positive predictive value, and data quality were average. Stability and simplicity were poor. The sensitivity was good. The main weaknesses in the tuberculosis surveillance system include a lack of governmental financial support, a paper-based system, and a lack of regular staff training. Developing an electronic system, securing governmental finances, and training the staff on tuberculosis surveillance are strongly recommended to improve the system performance.     

Implementing integrated disease surveillance and response: Four African countries' experience, 1998–2005

Abstract

The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy.

Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response.

The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels.     

Effectiveness of a Mobile Short-Message-Service–Based Disease Outbreak Alert System in Kenya

We conducted a randomized, controlled trial to test the effectiveness of a text-messaging system used for notification of disease outbreaks in Kenya. Health facilities that used the system had more timely notifications than those that did not (19.2% vs. 2.6%), indicating that technology can enhance disease surveillance in resource-limited settings.