Community-Based Surveillance in Côte d'Ivoire

Feasibility and challenges in sustaining a community based surveillance system in post-Ebola Sierra Leone

BACKGROUND

In outbreak-prone settings, community-based surveillance (CBS) systems can alert health authorities to respond in a timely manner where suspected cases of disease are being reported. After the 2014-2016 Ebola outbreak, the WHO and other stakeholders supported the establishment of CBS in Sierra Leone, for which community health workers (CHW) were trained to collect and report symptoms data of 11 priority health conditions in their communities. Our study objective was to assess feasibility and challenges to sustain CBS in a low resource setting as part of a World Bank evaluation of Sierra Leone's Ministry of Health and Sanitation's (MoHS) CBS and electronic Integrated Disease Surveillance & Response (eIDSR) systems.

METHODS

In 2019 we conducted a mixed methods assessment consisting of a household incidence survey, health facility survey, household case verification survey, a costing analysis, and in-depth interviews and focus group discussions with key stakeholders of the CBS system in eight chiefdoms of 4 purposefully selected districts in Sierra Leone. The study period for primary data collection was February through April 2019. We also conducted secondary data analysis of surveillance data in DHIS2 of all 32 chiefdoms.

RESULTS

In districts where CBS was 'fully functional', the number and type of CBS alerts corresponded to the number and type of diseases reported through facility based eIDSR system in the same period. However under-reporting of diarrhea and measles suspects from the community still appeared to occur, and reporting deteriorated when primary health care staff including CHWs reported the stoppage of stipends. The annual budget impact for CBS was estimated at 4.4 million USD in 2018. The majority of costs were made at community level (73%) compared to regional (0.3%), primary health unit (21%), district (4%) and national (2%) level. The most important costs drivers were training of CHWs (59% of total costs) and salaries (including stipends of the CHWs) of human resources (15%). Barriers included sustainable financing of human resources, internet connectivity, as well as limited trainings and supportive supervision, and unsupported transportation costs for CHWs and peer supervisors (PS). CHWs and community members reported that communities are more willing to share information about health issues compared to the pre-CBS implementation period.

CONCLUSIONS

The similarity between CBS and IDSR reports support the possibility that CBS increases the sensitivity of disease surveillance to the level of the community, which would enable local authorities to take early prevention measures when and where impact will be the greatest. Qualitative interviews suggest that CBS has improved the interface between the community and primary level of the health system. However if the barriers to sustainability are left unaddressed, opportunities for CBS to prevent disease outbreaks will go unrealized.

Public health surveillance through community health workers: a scoping review of evidence from 25 low-income and middle-income countries

BACKGROUND

The last 3 years have witnessed global health challenges, ranging from the pandemics of COVID-19 and mpox (monkeypox) to the Ebola epidemic in Uganda. Public health surveillance is critical for preventing these outbreaks, yet surveillance systems in resource-constrained contexts struggle to provide timely disease reporting. Although community health workers (CHWs) support health systems in low-income and middle-income countries (LMICs), very little has been written about their role in supporting public health surveillance. This review identified the roles, impacts and challenges CHWs face in public health surveillance in 25 LMICs.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's framework. We exported 1,156 peer-reviewed records from Embase, Global Health and PubMed databases. After multiple screenings, 29 articles were included in the final review.

RESULTS

CHWs significantly contribute to public health surveillance in LMICs including through contact tracing and patient visitation to control major infectious diseases such as HIV/AIDS, malaria, tuberculosis, Ebola, neglected tropical diseases and COVID-19. Their public health surveillance roles typically fall into four main categories including community engagement; data gathering; screening, testing and treating; and health education and promotion. The use of CHWs in public health surveillance in LMICs has been impactful and often involves incorporation of various technologies leading to improved epidemic control and disease reporting. Nonetheless, use of CHWs can come with four main challenges including lack of education and training, lack of financial and other resources, logistical and infrastructural challenges as well as community engagement challenges.

CONCLUSION

CHWs are important stakeholders in surveillance because they are closer to communities than other healthcare workers. Further integration and training of CHWs in public health surveillance would improve public health surveillance because CHWs can provide health data on 'hard-to-reach' populations. CHWs' work in public health surveillance would also be greatly enhanced by infrastructural investments.

Evaluating event-based surveillance capacity in Africa: Use of the Africa CDC scorecard, 2022-2023

Introduction

Event-based surveillance (EBS) is a critical component of Early Warning, Alert and Response (EWAR) capacity needed for outbreak prevention and control. To better understand existing EBS and monitor the progress of capacity-building efforts over time, Africa CDC developed an EBS scorecard as part of a revision to the EBS Framework.

Methods

We distributed the scorecard to African Union (AU) Member States (MSs). Survey responses from the MSs' human health sector were aggregated, cleaned, and analysed. MS, regional, and continental EBS capacity was assessed.

Results

Between 21 July 2022 and 4 April 2023, a total of 63 respondents representing 49 (89%) of 55 MSs completed the survey. Given Africa CDC's public health mandate, we acknowledged the importance of One Health collaboration in MSs but focused on and analysed only the human health sector responses. Thirty-four (71%) MSs stated having EBS in place; hotline was the most common type of EBS implemented (76%). Seventeen (50%) MSs reported multisectoral, One Health collaboration as part of EBS implementation. Scorecard outcomes showed a minimal (score of <60%) to average (score between 60-80%) level of EBS capacity in 29 and five (5) MSs respectively.

Discussion

Current EBS capacity levels need to be strengthened in Africa to ensure the continent remains prepared for future public health threats. The Africa CDC EBS scorecard provides a useful way to measure and track this capacity over time. Results can be used to advocate for and target resources for capacity building to foster public health emergency preparedness efforts.

Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics

INTRODUCTION

This systematic review aimed to analyse the performance of the Integrated Disease Surveillance and Response (IDSR) strategy in Sub-Saharan Africa (SSA) and how its implementation has embraced advancement in information technology, big data analytics techniques and wealth of data sources.

METHODS

HINARI, PubMed, and advanced Google Scholar databases were searched for eligible articles. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols.

RESULTS

A total of 1,809 articles were identified and screened at two stages. Forty-five studies met the inclusion criteria, of which 35 were country-specific, seven covered the SSA region, and three covered 3-4 countries. Twenty-six studies assessed the IDSR core functions, 43 the support functions, while 24 addressed both functions. Most of the studies involved Tanzania (9), Ghana (6) and Uganda (5). The routine Health Management Information System (HMIS), which collects data from health care facilities, has remained the primary source of IDSR data. However, the system is characterised by inadequate data completeness, timeliness, quality, analysis and utilisation, and lack of integration of data from other sources. Under-use of advanced and big data analytical technologies in performing disease surveillance and relating multiple indicators minimises the optimisation of clinical and practice evidence-based decision-making.

CONCLUSIONS

This review indicates that most countries in SSA rely mainly on traditional indicator-based disease surveillance utilising data from healthcare facilities with limited use of data from other sources. It is high time that SSA countries consider and adopt multi-sectoral, multi-disease and multi-indicator platforms that integrate other sources of health information to provide support to effective detection and prompt response to public health threats.

Participatory surveillance of COVID-19 in Lesotho via weekly calls: Protocol for cell phone data collection

Background

The increase in cell phone ownership in low- and middle-income countries (LMIC) has created an opportunity for low-cost, rapid data collection by calling participants on their cell phones. Cell phones can be mobilized for a myriad of data collection purposes, including surveillance. In LMIC, cell phone–based surveillance has been used to track Ebola, measles, acute flaccid paralysis, and diarrheal disease, as well as noncommunicable diseases. Phone-based surveillance in LMIC is a particularly pertinent, burgeoning approach in the context of the COVID-19 pandemic. Participatory surveillance via cell phone could allow governments to assess burden of disease and complements existing surveillance systems.

Objective

We describe the protocol for the LeCellPHIA (Lesotho Cell Phone PHIA) project, a cell phone surveillance system that collects weekly population-based data on influenza-like illness (ILI) in Lesotho by calling a representative sample of a recent face-to-face survey.

Methods

We established a phone-based surveillance system to collect ILI symptoms from approximately 1700 participants who had participated in a recent face-to-face survey in Lesotho, the Population-based HIV Impact Assessment (PHIA) Survey. Of the 15,267 PHIA participants who were over 18 years old, 11,975 (78.44%) consented to future research and provided a valid phone number. We followed the PHIA sample design and included 342 primary sampling units from 10 districts. We randomly selected 5 households from each primary sampling unit that had an eligible participant and sampled 1 person per household. We oversampled the elderly, as they are more likely to be affected by COVID-19. A 3-day Zoom training was conducted in June 2020 to train LeCellPHIA interviewers.

Results

The surveillance system launched July 1, 2020, beginning with a 2-week enrollment period followed by weekly calls that will continue until September 30, 2022. Of the 11,975 phone numbers that were in the sample frame, 3020 were sampled, and 1778 were enrolled.

Conclusions

The surveillance system will track COVID-19 in a resource-limited setting. The novel approach of a weekly cell phone–based surveillance system can be used to track other health outcomes, and this protocol provides information about how to implement such a system.

International Registered Report Identifier (IRRID)

DERR1-10.2196/31236

People-centred surveillance: a narrative review of community-based surveillance among crisis-affected populations

Outbreaks of disease in settings affected by crises grow rapidly due to late detection and weakened public health systems. Where surveillance is underfunctioning, community-based surveillance can contribute to rapid outbreak detection and response, a core capacity of the International Health Regulations. We reviewed articles describing the potential for community-based surveillance to detect diseases of epidemic potential, outbreaks, and mortality among populations affected by crises. Surveillance objectives have included the early warning of outbreaks, active case finding during outbreaks, case finding for eradication programmes, and mortality surveillance. Community-based surveillance can provide sensitive and timely detection, identify valid signals for diseases with salient symptoms, and provide continuity in remote areas during cycles of insecurity. Effectiveness appears to be mediated by operational requirements for continuous supervision of large community networks, verification of a large number of signals, and integration of community-based surveillance within the routine investigation and response infrastructure. Similar to all community health systems, community-based surveillance requires simple design, reliable supervision, and early and routine monitoring and evaluation to ensure data validity. Research priorities include the evaluation of syndromic case definitions, electronic data collection for community members, sentinel site designs, and statistical techniques to counterbalance false positive signals.