Assessment of Community Event-Based Surveillance for Ebola Virus Disease, Sierra Leone, 2015

Evaluation of a multi-component early warning system for pastoralist populations in Doolo zone, Ethiopia: mixed-methods study

BACKGROUND

This study evaluated an early warning, alert and response system for a crisis-affected population in Doolo zone, Somali Region, Ethiopia, in 2019-2021, with a history of epidemics of outbreak-prone diseases. To adequately cover an area populated by a semi-nomadic pastoralist, or livestock herding, population with sparse access to healthcare facilities, the surveillance system included four components: health facility indicator-based surveillance, community indicator- and event-based surveillance, and alerts from other actors in the area. This evaluation described the usefulness, acceptability, completeness, timeliness, positive predictive value, and representativeness of these components.

METHODS

We carried out a mixed-methods study retrospectively analysing data from the surveillance system February 2019-January 2021 along with key informant interviews with system implementers, and focus group discussions with local communities. Transcripts were analyzed using a mixed deductive and inductive approach. Surveillance quality indicators assessed included completeness, timeliness, and positive predictive value, among others.

RESULTS

1010 signals were analysed; these resulted in 168 verified events, 58 alerts, and 29 responses. Most of the alerts (46/58) and responses (22/29) were initiated through the community event-based branch of the surveillance system. In comparison, one alert and one response was initiated via the community indicator-based branch. Positive predictive value of signals received was about 6%. About 80% of signals were verified within 24 h of reports, and 40% were risk assessed within 48 h. System responses included new mobile clinic sites, measles vaccination catch-ups, and water and sanitation-related interventions. Focus group discussions emphasized that responses generated were an expected return by participant communities for their role in data collection and reporting. Participant communities found the system acceptable when it led to the responses they expected. Some event types, such as those around animal health, led to the community's response expectations not being met.

CONCLUSIONS

Event-based surveillance can produce useful data for localized public health action for pastoralist populations. Improvements could include greater community involvement in the system design and potentially incorporating One Health approaches.

Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: A scoping review

OBJECTIVES

There is a paucity of scoping data on the specific roles community engagement played in preventing and managing the Ebola virus disease (EVD) outbreak in sub-Saharan Africa. We assessed the role, benefits, and mechanisms of community engagement to understand its effect on EVD case detection, survival, and mortality in sub-Saharan Africa. The implications for COVID-19 prevention and control were also highlighted.

METHODS

We searched for articles between 2010 and 2020 in the MEDLINE and Embase databases. The study types included were randomized trials, quasiexperimental studies, observational studies, case series, and reports.

RESULTS

A total of 903 records were identified for screening. A total of 216 articles met the review criteria, 103 were initially selected, and 44 were included in the final review. Our findings show that effective community involvement during the EVD outbreak depended on the survival rates, testimonials of survivors, risk perception, and the inclusion of community leaders. Community-based interventions improved knowledge and attitudes, case findings, isolation efforts, and treatment uptake.

CONCLUSION

Although the studies included in this review were of highly variable quality, findings from this review may provide lessons for the role of community engagement in the COVID-19 pandemic's prevention and control in sub-Saharan Africa.

Structure, functions, performance and gaps of event-based surveillance (EBS) in Sudan, 2021: a cross-sectional review

BACKGROUND

Event-based surveillance (EBS) is an essential component of Early Warning Alert and Response (EWAR) as per the International Health Regulations (IHR), 2005. EBS was established in Sudan in 2016 as a complementary system for Indicator-based surveillance (IBS). This review will provide an overview of the current EBS structure, functions and performance in Sudan and identify the gaps and ways forward.  METHODS: The review followed the WHO/EMRO guidelines and tools. Structured discussions, observation and review of records and guidelines were done at national and state levels. Community volunteers were interviewed through phone calls. Directors of Health Emergency and Epidemic Control, surveillance officers and focal persons for EBS at the state level were also interviewed. SPSS software was used to perform descriptive statistical analysis for quantitative data, while qualitative data was analysed manually using thematic analysis, paying particular attention to the health system level allowing for an exploration of how and why experiences differ across levels. Written and verbal consents were obtained from all participants as appropriate.

RESULTS

Sudan has a functioning EBS; however, there is an underestimation of its contribution and importance at the national and states levels. The link between the national level and states is ad hoc or is driven by the need for reports. While community event-based surveillance (CEBS) is functioning, EBS from health facilities and from non-health sectors is not currently active. The integration of EBS into overall surveillance was not addressed, and the pathway from detection to action is not clear. The use of electronic databases and platforms is generally limited. Factors that would improve performance include training, presence of a trained focal person at state level, and regular follow-up from the national level. Factors such as staff turnover, income in relation to expenses and not having a high academic qualification (Diploma or MSc) were noticed as inhibiting factors.

CONCLUSION

The review recommended revisiting the surveillance structure at national and state levels to put EBS as an essential component and to update guidelines and standard operation procedures SOPs to foster the integration between EBS components and the overall surveillance system. The need for strengthening the link with states, capacity building and re-addressing the training modalities was highlighted.

Effectiveness of early warning systems in the detection of infectious diseases outbreaks: a systematic review

Background

Global pandemics have occurred with increasing frequency over the past decade reflecting the sub-optimum operationalization of surveillance systems handling human health data. Despite the wide array of current surveillance methods, their effectiveness varies with multiple factors. Here, we perform a systematic review of the effectiveness of alternative infectious diseases Early Warning Systems (EWSs) with a focus on the surveillance data collection methods, and taking into consideration feasibility in different settings.

Methods

We searched PubMed and Scopus databases on 21 October 2022. Articles were included if they covered the implementation of an early warning system and evaluated infectious diseases outbreaks that had potential to become pandemics. Of 1669 studies screened, 68 were included in the final sample. We performed quality assessment using an adapted CASP Checklist.

Results

Of the 68 articles included, 42 articles found EWSs successfully functioned independently as surveillance systems for pandemic-wide infectious diseases outbreaks, and 16 studies reported EWSs to have contributing surveillance features through complementary roles. Chief complaints from emergency departments’ data is an effective EWS but it requires standardized formats across hospitals. Centralized Public Health records-based EWSs facilitate information sharing; however, they rely on clinicians’ reporting of cases. Facilitated reporting by remote health settings and rapid alarm transmission are key advantages of Web-based EWSs. Pharmaceutical sales and laboratory results did not prove solo effectiveness. The EWS design combining surveillance data from both health records and staff was very successful. Also, daily surveillance data notification was the most successful and accepted enhancement strategy especially during mass gathering events. Eventually, in Low Middle Income Countries, working to improve and enhance existing systems was more critical than implementing new Syndromic Surveillance approaches.

Conclusions

Our study was able to evaluate the effectiveness of Early Warning Systems in different contexts and resource settings based on the EWSs’ method of data collection. There is consistent evidence that EWSs compiling pre-diagnosis data are more proactive to detect outbreaks. However, the fact that Syndromic Surveillance Systems (SSS) are more proactive than diagnostic disease surveillance should not be taken as an effective clue for outbreaks detection.

The performance of COVID-19 Surveillance System as timely containment strategy in Western Oromia, Ethiopia

BACKGROUND

COVID-19 has been swiftly spreading throughout the world ever since it emerged in Wuhan, China, in late December 2019. Case detection and contact identification remain the key surveillance objectives for effective containment of the pandemic. This study was aimed at assessing performance of surveillance in early containment of COVID 19 in Western Oromia, Ethiopia.

METHODS

A cross-sectional study was conducted from August 1 to September 30, 2020, in the 7 kebeles of Nekemte and 2 kebeles of Shambu Town. Residents who lived there for at least the past six months were considered eligible for this study. Data were collected from community and health system at different levels using semi structured questionnaire and checklist, respectively. Participants' health facility usage (dependent variable) and perceived risk, awareness, Socioeconomic Status, and practices (independent variable) were assessed. Bivariable analysis was computed to test the presence of an association between dependent and independent variables. Independent predictors were identified on multivariable logistic regression using a p-value of (<0.05) significance level. We have checked the model goodness of fit test by Hosmer-lemeshow test.

RESULTS

One hundred seventy-nine (41%) of the participants believe that they have a high risk of contracting COVID-19 and 127 (29%) of them reported they have been visited by health extension worker. One hundred ninety-seven (45.2%) reported that they were not using health facilities for routine services during this pandemic. Except one hospital, all health facilities (92%) were using updated case definition. Three (33%) of the assessed health posts didn't have community volunteers. On multivariable logistic regression analysis, the source of income AOR=0.30, 95% CI (0.11, 0.86), perceived level of risk AOR=3.42, 95% CI (2.04, 5.7) and not visited by health extension workers AOR=0.46, 95% CI (0.29, 0.74) were found to be independent predictors of not using health facilities during this pandemic.

CONCLUSION

Event based surveillance, both at community and health facility level, was not performing optimally in identifying potential suspects. Therefore, for effective early containment of epidemic, it is critical to strengthen event based surveillance and make use of surveillance data for tailored intervention in settings where mass testing is not feasible.

Evaluation of Early Warning, Alert and Response System for Ebola Virus Disease, Democratic Republic of the Congo, 2018-2020

The 10th and largest Ebola virus disease epidemic in the Democratic Republic of the Congo (DRC) was declared in North Kivu Province in August 2018 and ended in June 2020. We describe and evaluate an Early Warning, Alert and Response System (EWARS) implemented in the Beni health zone of DRC during August 5, 2018–June 30, 2020. During this period, 194,768 alerts were received, of which 30,728 (15.8%) were validated as suspected cases. From these, 801 confirmed and 3 probable cases were detected. EWARS showed an overall good performance: sensitivity and specificity >80%, nearly all (97%) of alerts investigated within 2 hours of notification, and good demographic representativeness. The average cost of the system was US $438/case detected and US $1.8/alert received. The system was stable, despite occasional disruptions caused by political insecurity. Our results demonstrate that EWARS was a cost-effective component of the Ebola surveillance strategy in this setting.

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.

Community-based surveillance in internally displaced people's camps and urban settings during a complex emergency in Yemen in 2020

Background

The need for early identification of coronavirus disease (COVID-19) cases in communities was high in Yemen during the first wave of the COVID-19 epidemic because most cases presenting to health facilities were severe. Early detection of cases would allow early interventions to interrupt the transmission chains. This study aimed to describe the implementation of community-based surveillance (CBS) in in internally displaced people (IDP) camps and urban settings in Yemen from 15 April 2020 to 30 September 2020.

Methods

Following the Centers for Disease Control and Prevention guidance for evaluation of surveillance systems, we assessed the usefulness and acceptability of CBS. For acceptability, we calculated the proportion of trained volunteers who reported disease alerts. To assess the usefulness, we compared the alerts reported through the electronic diseases early warning system (eDEWS) with the alerts reported through CBS and described the response activities implemented.

Results

In Al-Mukalla City, 18% (14/78) of the volunteers reported at least one alert. In IDP camps, 58% (18/31) of volunteers reported at least one alert. In Al-Mukalla City, CBS detected 49 alerts of influenza-like illness, whereas health facilities detected 561 cases of COVID-19. In IDP camps, CBS detected 91 alerts of influenza-like illness, compared to 10 alerts detected through eDEWS. In IDP camps, CBS detected three other syndromes besides influenza-like illness (febrile illness outbreak suspicion, acute diarrhoea, and skin disease). In IDP camps, public health actions were implemented for each disease detected and no further cases were reported.

Conclusions

In Yemen, CBS was useful for detecting suspected outbreaks in IDP camps. CBS implementation did not yield expected results in general communities in urban areas in the early stage of the COVID-19 pandemic when little was known about the disease. In the urban setting, the system failed to detect suspected COVID-19 cases and other diseases despite the ongoing outbreaks reported through eDEWS. In Yemen, as in other countries, feasibility and acceptability studies should be conducted few months before CBS expansion in urban communities. The project should be expanded in IDP camps, by creating COVID-19 and other disease outbreak reporting sites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00394-1.

Evaluation of National Event-Based Surveillance, Nigeria, 2016-2018

Nigeria Centres for Disease Control and Prevention established an event-based surveillance (EBS) system in 2016 to supplement traditional surveillance structures. The EBS system is comprised of an internet-based data mining tool and a call center. To evaluate the EBS system for usefulness, simplicity, acceptability, timeliness, and data quality, we performed a descriptive analysis of signals received during September 2017–June 2018. We used questionnaires, semistructured interviews, and direct observation to collect information from EBS staff. Amongst 43,631 raw signals detected, 138 (0.3%) were escalated; 63 (46%) of those were verified as events, including 25 Lassa fever outbreaks and 13 cholera outbreaks. Interviewees provided multiple examples of earlier outbreak detections but suggested notifications and logging could be improved to ensure action. EBS proved effective in detecting outbreaks, but we noted clear opportunities for efficiency gains. We recommend improving signal logging, standardizing processes, and revising outputs to ensure appropriate public health action.

Integrated digital system for community engagement and community-based surveillance during the 2014-2016 Ebola outbreak in Sierra Leone: lessons for future health emergencies

Community engagement and community-based surveillance are essential components of responding to infectious disease outbreaks, but real-time data reporting remains a challenge. In the 2014-2016 Ebola outbreak in Sierra Leone, the Social Mobilisation Action Consortium was formed to scale-up structured, data-driven community engagement. The consortium became operational across all 14 districts and supported an expansive network of 2500 community mobilisers, 6000 faith leaders and 42 partner radio stations. The benefit of a more agile digital reporting system became apparent within few months of implementing paper-based reporting given the need to rapidly use the data to inform the fast-evolving epidemic. In this paper, we aim to document the design, deployment and implementation of a digital reporting system used in six high transmission districts. We highlight lessons learnt from our experience in scaling up the digital reporting system during an unprecedented public health crisis. The lessons learnt from our experience in Sierra Leone have important implications for designing and implementing similar digital reporting systems for community engagement and community-based surveillance during public health emergencies.

Barriers and facilitators to reporting deaths following Ebola surveillance in Sierra Leone: implications for sustainable mortality surveillance based on an exploratory qualitative assessment

OBJECTIVES

To understand the barriers contributing to the more than threefold decline in the number of deaths (of all causes) reported to a national toll free telephone line (1-1-7) after the 2014-2016 Ebola outbreak ended in Sierra Leone and explore opportunities for improving routine death reporting as part of a nationwide mortality surveillance system.

DESIGN

An exploratory qualitative assessment comprising 32 in-depth interviews (16 in Kenema district and 16 in Western Area). All interviews were audio-recorded, transcribed and analysed using qualitative content analysis to identify themes.

SETTING

Participants were selected from urban and rural communities in two districts that experienced varying levels of Ebola cases during the outbreak. All interviews were conducted in August 2017 in the post-Ebola-outbreak context in Sierra Leone when the Sierra Leone Ministry of Health and Sanitation was continuing to mandate reporting of all deaths.

PARTICIPANTS

Family members of deceased persons whose deaths were not reported to the 1-1-7 system.

RESULTS

Death reporting barriers were driven by the lack of awareness to report all deaths, lack of services linked to reporting, negative experiences from the Ebola outbreak including prohibition of traditional burial rituals, perception that inevitable deaths do not need to be reported and situations where prompt burials may be needed. Facilitators of future willingness to report deaths were largely influenced by the perceived communicability and severity of the disease, unexplained circumstances of the death that need investigation and the potential to leverage existing death notification practices through local leaders.

CONCLUSIONS

Social mobilisation and risk communication efforts are needed to help the public understand the importance and benefits of sustained and ongoing death reporting after an Ebola outbreak. Localised practices for informal death notification through community leaders could be integrated into the formal reporting system to capture community-based deaths that may otherwise be missed.

Evaluation of community based surveillance in the Rohingya refugee camps in Cox's Bazar, Bangladesh, 2019

BACKGROUND

Following an influx of an estimated 742,000 Rohingya refugees in Bangladesh, Médecins sans Frontières (MSF) established an active indicator-based Community Based Surveillance (CBS) in 13 sub-camps in Cox's Bazar in August 2017. Its objective was to detect epidemic prone diseases early for rapid response. We describe the surveillance, alert and response in place from epidemiological week 20 (12 May 2019) until 44 (2 November 2019).

METHODS

Suspected cases were identified through passive health facility surveillance and active indicator-based CBS. CBS-teams conducted active case finding for suspected cases of acute watery diarrhea (AWD), acute jaundice syndrome (AJS), acute flaccid paralysis (AFP), dengue, diphtheria, measles and meningitis. We evaluate the following surveillance system attributes: usefulness, Positive Predictive Value (PPV), timeliness, simplicity, flexibility, acceptability, representativeness and stability.

RESULTS

Between epidemiological weeks 20 and 44, an average of 97,340 households were included in the CBS per surveillance cycle. Household coverage reached over 85%. Twenty-one RDT positive cholera cases and two clusters of AWD were identified by the CBS and health facility surveillance that triggered the response mechanism within 12 hours. The PPV of the CBS varied per disease between 41.7%-100%. The CBS required 354 full-time staff in 10 different roles. The CBS was sufficiently flexible to integrate dengue surveillance. The CBS was representative of the population in the catchment area due to its exhaustive character and high household coverage. All households consented to CBS participation, showing acceptability.

DISCUSSION

The CBS allowed for timely response but was resource intensive. Disease trends identified by the health facility surveillance and suspected diseases trends identified by CBS were similar, which might indicate limited additional value of the CBS in a dense and stable setting such as Cox's Bazar. Instead, a passive community-event-based surveillance mechanism combined with health facility-based surveillance could be more appropriate.

The practice of evaluating epidemic response in humanitarian and low-income settings: a systematic review

BACKGROUND

Epidemics of infectious disease occur frequently in low-income and humanitarian settings and pose a serious threat to populations. However, relatively little is known about responses to these epidemics. Robust evaluations can generate evidence on response efforts and inform future improvements. This systematic review aimed to (i) identify epidemics reported in low-income and crisis settings, (ii) determine the frequency with which evaluations of responses to these epidemics were conducted, (iii) describe the main typologies of evaluations undertaken and (iv) identify key gaps and strengths of recent evaluation practice.

METHODS

Reported epidemics were extracted from the following sources: World Health Organization Disease Outbreak News (WHO DON), UNICEF Cholera platform, Reliefweb, PROMED and Global Incidence Map. A systematic review for evaluation reports was conducted using the MEDLINE, EMBASE, Global Health, Web of Science, WPRIM, Reliefweb, PDQ Evidence and CINAHL Plus databases, complemented by grey literature searches using Google and Google Scholar. Evaluation records were quality-scored and linked to epidemics based on time and place. The time period for the review was 2010-2019.

RESULTS

A total of 429 epidemics were identified, primarily in sub-Saharan Africa, the Middle East and Central Asia. A total of 15,424 potential evaluations records were screened, 699 assessed for eligibility and 132 included for narrative synthesis. Only one tenth of epidemics had a corresponding response evaluation. Overall, there was wide variability in the quality, content as well as in the disease coverage of evaluation reports.

CONCLUSION

The current state of evaluations of responses to these epidemics reveals large gaps in coverage and quality and bears important implications for health equity and accountability to affected populations. The limited availability of epidemic response evaluations prevents improvements to future public health response. The diversity of emphasis and methods of available evaluations limits comparison across responses and time. In order to improve future response and save lives, there is a pressing need to develop a standardized and practical approach as well as governance arrangements to ensure the systematic conduct of epidemic response evaluations in low-income and crisis settings.

Africa Centres for Disease Control and Prevention Is Closing Gaps in Disease Detection

In 2017, the African Union established a new continent-wide public health agency, the Africa Centres for Disease Control and Prevention (Africa CDC). Many outbreaks are never detected in Africa, and among outbreaks that are detected, countries often respond slowly and ineffectively. To address these problems, Africa CDC is working to increase early detection and reporting, improve access to diagnostic tests, promote novel laboratory approaches, help establish national public health institutes, improve information exchange between health agencies, and enhance recording and reporting of acute public health events and vital statistics. The health security of Africa will be strengthened by this new public health agency's ability to build comprehensive, timely disease surveillance that rapidly detects and contains health threats.

Community engagement for COVID-19 prevention and control: a rapid evidence synthesis

INTRODUCTION

Community engagement has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and 'bottom-up' approaches used within COVID-19 responses thus far. Identifying how community engagement approaches have been used in past epidemics may support more robust implementation within the COVID-19 response.

METHODOLOGY

A rapid evidence review was conducted to identify how community engagement is used for infectious disease prevention and control during epidemics. Three databases were searched in addition to extensive snowballing for grey literature. Previous epidemics were limited to Ebola, Zika, SARS, Middle East respiratory syndromeand H1N1 since 2000. No restrictions were applied to study design or language.

RESULTS

From 1112 references identified, 32 articles met our inclusion criteria, which detail 37 initiatives. Six main community engagement actors were identified: local leaders, community and faith-based organisations, community groups, health facility committees, individuals and key stakeholders. These worked on different functions: designing and planning, community entry and trust building, social and behaviour change communication, risk communication, surveillance and tracing, and logistics and administration.

CONCLUSION

COVID-19's global presence and social transmission pathways require social and community responses. This may be particularly important to reach marginalised populations and to support equity-informed responses. Aligning previous community engagement experience with current COVID-19 community-based strategy recommendations highlights how communities can play important and active roles in prevention and control. Countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific, acceptable and appropriate COVID-19 prevention and control measures.

Community-Based Surveillance in Côte d'Ivoire

Community-based surveillance can be an important component of early warning systems. In 2016, the Côte d'Ivoire Ministry of Health launched a community-based surveillance project in 3 districts along the Guinea border. Community health workers were trained in detection and immediate reporting of diseases and events using a text-messaging platform. In December 2017, surveillance data from before and after implementation of community-based surveillance were analyzed in intervention and control districts. A total of 3,734 signals of priority diseases and 4,918 unusual health events were reported, of which 420 were investigated as suspect diseases and none were investigated as unusual health events. Of the 420 suspected cases reported, 23 (6%) were laboratory confirmed for a specific pathogen. Following implementation of community-based surveillance, 5-fold and 8-fold increases in reporting of suspected measles and yellow fever clusters, respectively, were documented. Reporting incidence rates in intervention districts for suspected measles, yellow fever, and acute flaccid paralysis were significantly higher after implementation, with a difference of 29.2, 19.0, and 2.5 cases per 100,000 person-years, respectively. All rate differences were significantly higher in intervention districts (p < 0.05); no significant increase in reporting was noted in control districts. These findings suggest that community-based surveillance strengthened detection and reporting capacity for several suspect priority diseases and events. However, the surveillance program was very sensitive, resulting in numerous false-positives. Learning from the community-based surveillance implementation experience, the ministry of health is revising signal definitions to reduce sensitivity and increase specificity, reviewing training materials, considering scaling up sustainable reporting platforms, and standardizing community health worker roles.

Community engagement for COVID-19 prevention and control: a rapid evidence synthesis

INTRODUCTION

Community engagement has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and 'bottom-up' approaches used within COVID-19 responses thus far. Identifying how community engagement approaches have been used in past epidemics may support more robust implementation within the COVID-19 response.

METHODOLOGY

A rapid evidence review was conducted to identify how community engagement is used for infectious disease prevention and control during epidemics. Three databases were searched in addition to extensive snowballing for grey literature. Previous epidemics were limited to Ebola, Zika, SARS, Middle East respiratory syndromeand H1N1 since 2000. No restrictions were applied to study design or language.

RESULTS

From 1112 references identified, 32 articles met our inclusion criteria, which detail 37 initiatives. Six main community engagement actors were identified: local leaders, community and faith-based organisations, community groups, health facility committees, individuals and key stakeholders. These worked on different functions: designing and planning, community entry and trust building, social and behaviour change communication, risk communication, surveillance and tracing, and logistics and administration.

CONCLUSION

COVID-19's global presence and social transmission pathways require social and community responses. This may be particularly important to reach marginalised populations and to support equity-informed responses. Aligning previous community engagement experience with current COVID-19 community-based strategy recommendations highlights how communities can play important and active roles in prevention and control. Countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific, acceptable and appropriate COVID-19 prevention and control measures.

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.

Developing monitoring and evaluation tools for event-based surveillance: experience from Vietnam

BACKGROUND

In 2016-2017, Vietnam's Ministry of Health (MoH) implemented an event-based surveillance (EBS) pilot project in six provinces as part of Global Health Security Agenda (GHSA) efforts. This manuscript describes development and design of tools for monitoring and evaluation (M&E) of EBS in Vietnam.

METHODS

A strategic EBS framework was developed based on the EBS implementation pilot project's goals and objectives. The main process and outcome components were identified and included input, activities, outputs, and outcome indicators. M&E tools were developed to collect quantitative and qualitative data. The tools included a supervisory checklist, a desk review tool, a key informant interview guide, a focus group discussion guide, a timeliness form, and an online acceptability survey. An evaluation team conducted field visits for assessment of EBS 5-9 months after implementation.

RESULTS

The quantitative data collected provided evidence on the number and type of events that were being reported, the timeliness of the system, and the event-to-signal ratio. The qualitative and subjective data collected helped to increase understanding of the system's field utility and acceptance by field staff, reasons for non-compliance with established guidelines, and other factors influencing implementation.

CONCLUSIONS

The use of M&E tools for the EBS pilot project in Vietnam provided data on signals and events reported, timeliness of reporting and response, perceptions and opinions of implementers, and fidelity of EBS implementation. These data were valuable for Vietnam's MoH to understand the function of the EBS program, and the success and challenges of implementing this project in Vietnam.

Rigorous surveillance is necessary for high confidence in end-of-outbreak declarations for Ebola and other infectious diseases

The World Health Organization considers an Ebola outbreak to have ended once 42 days have passed since the last possible exposure to a confirmed case. Benefits of a quick end-of-outbreak declaration, such as reductions in trade/travel restrictions, must be balanced against the chance of flare-ups from undetected residual cases. We show how epidemiological modelling can be used to estimate the surveillance level required for decision-makers to be confident that an outbreak is over. Results from a simple model characterizing an Ebola outbreak suggest that a surveillance sensitivity (i.e. case reporting percentage) of 79% is necessary for 95% confidence that an outbreak is over after 42 days without symptomatic cases. With weaker surveillance, unrecognized transmission may still occur: if the surveillance sensitivity is only 40%, then 62 days must be waited for 95% certainty. By quantifying the certainty in end-of-outbreak declarations, public health decision-makers can plan and communicate more effectively. This article is part of the theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: epidemic forecasting and control'. This issue is linked with the earlier theme issue 'Modelling infectious disease outbreaks in humans, animals and plants: approaches and important themes'.

Strengthening timely detection and reporting of unusual respiratory events from health facilities in Yaoundé, Cameroon

BACKGROUND

The International Health Regulations state that early detection and immediate reporting of unusual health events is important for early warning and response systems.

OBJECTIVE

To describe a pilot surveillance program established in health facilities in Yaoundé, Cameroon in 2017 which aimed to enable detection and reporting of public health events.

METHODS

Cameroon's Ministry of Health, in partnership with the US Centers for Disease Control and Prevention, Cameroon Pasteur Center, and National Public Health Laboratory, implemented event-based surveillance (EBS) in nine Yaoundé health facilities. Four signals were defined that could indicate possible public health events, and a reporting, triage, and verification system was established among partner organizations. A pre-defined laboratory algorithm was defined, and a series of workshops trained health facilities, laboratory, and public health staff for surveillance implementation.

RESULTS

From May 2017 to January 2018, 30 signals were detected, corresponding to 15 unusual respiratory events. All health facilities reported a signal at least once, and more than three-quarters of health facilities reported ≥2 times. Among specimens tested, the pathogens detected included Klebsiella pneumoniae, Moraxella catarrhalis, Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus, Pneumocystis jiroveci, influenza A (H1N1) virus, rhinovirus, and adenovirus.

CONCLUSIONS

The events detected in this pilot were caused by routine respiratory bacteria and viruses, and no novel influenza viruses or other emerging respiratory threats were identified. The surveillance system, however, strengthened relationships and communication linkages between health facilities and public health authorities. Astute clinicians can play a critical role in early detection and EBS is one approach that may enable reporting of emerging outbreaks and public health events.

Unmet needs and behaviour during the Ebola response in Sierra Leone: a retrospective, mixed-methods analysis of community feedback from the Social Mobilization Action Consortium

BACKGROUND

The west African Ebola epidemic (2014-15) necessitated behaviour change in settings with prevalent and pre-existing unmet needs as well as extensive mechanisms for local community action. We aimed to assess spatial and temporal trends in community-reported needs and associations with behaviour change, community engagement, and the overall outbreak situation in Sierra Leone.

METHODS

We did a retrospective, mixed-methods study. Post-hoc analyses of data from 12 096 mobiliser visits as part of the Social Mobilization Action Consortium were used to describe the evolution of satisfied and unsatisfied needs (basic, security, autonomy, respect, and social support) between Nov 12, 2014, and Dec 18, 2015, and across 14 districts. Via Bayesian hierarchical regression modelling, we investigated associations between needs categories and behaviours (numbers of individuals referred to treatment within 24 h of symptom onset or deaths responded to with safe and dignified burials) and the role of community engagement programme status (initial vs follow-up visit) in the association between satisfied versus unsatisfied needs and behaviours.

FINDINGS

In general, significant associations were observed between unsatisfied needs categories and both prompt referrals to treatment and safe burials. Most notably, communities expressing unsatisfied capacity needs reported fewer safe burials (relative risk [RR] 0·86, 95% credible interval [CrI] 0·82-0·91) and fewer prompt referrals to treatment (RR 0·76, 0·70-0·83) than did those without unsatisfied capacity needs. The exception was expression of unsatisfied basic needs, which was associated with significantly fewer prompt referrals only (RR 0·86, 95% CrI 0·79-0·93). Compared with triggering visits by community mobilisers, follow-up visits were associated with higher numbers of prompt referrals (RR 1·40, 95% CrI 1·30-1·50) and safe burials (RR 1·08, 1·02-1·14).

INTERPRETATION

Community-based development of locally feasible, locally owned action plans, with the support of community mobilisers, has potential to address unmet needs for more sustained behaviour change in outbreak settings.

FUNDING

Bill & Melinda Gates, Bill & Melinda Gates Foundation, and National Institutes of Health.

Event-based surveillance at health facility and community level in low-income and middle-income countries: a systematic review

Background

The International Health Regulations require member states to establish “capacity to detect, assess, notify and report events”. Event-based surveillance (EBS) can contribute to rapid detection of acute public health events. This is particularly relevant in low-income and middle-income countries (LMICs) which may have poor public health infrastructure. To identify best practices, we reviewed the literature on the implementation of EBS in LMICs to describe EBS structures and to evaluate EBS systems.

Methods

We conducted a systematic literature search of six databases to identify articles that evaluated EBS in LMICs and additionally searched for grey literature. We used a framework approach to facilitate qualitative data synthesis and exploration of patterns across and within articles.

Results

We identified 778 records, of which we included 15 studies concerning 13 different EBS systems. The 13 EBS systems were set up as community-based surveillance, health facility-based surveillance or open surveillance (ie, notification by non-defined individuals and institutions). Four systems were set up in outbreak settings and nine outside outbreaks. All EBS systems were integrated into existing routine surveillance systems and pre-existing response structures to some extent. EBS was described as useful in detecting a large scope of events, reaching remote areas and guiding outbreak response.

Conclusion

Health facility and community-based EBS provide valuable information that can strengthen the early warning function of national surveillance systems. Integration into existing early warning and response systems was described as key to generate data for action and to facilitate rapid verification and response. Priority in its implementation should be given to settings that would particularly benefit from EBS strengths. This includes areas most prone to outbreaks and where traditional ‘routine’ surveillance is suboptimal.

Evaluation of the Functionality and Effectiveness of the CORE Group Polio Project's Community-Based Acute Flaccid Paralysis Surveillance System in South Sudan

This article describes the functionality and effectiveness of a community-based acute flaccid paralysis (AFP) surveillance system designed and implemented by the CORE Group Polio Project (CGPP) in conflict-affected and inaccessible areas of South Sudan between October 2015 and September 2017. The findings are based on interviews with key informants and focus group discussions as well as data from the CGPP and the management information system of the WHO. Through the implementing partners, the CGPP identified and built the capacity of the community-based surveillance (CBS) system, a system consisting of county supervisors, payam (sub-county) assistants, and community key informants. This structure played a critical role in the identification and reporting of AFP cases. The CGPP also established partnerships with other key players-local and international-to reach greater numbers of people, particularly displaced populations. Evaluation findings show an increase from 0.0% to 56.4% of cases reported through the CBS system between January 2016 and June 2017, and 80.0% of the cases reported within WHO standards of 24-48 hours were through the CBS system, whereas 20.0% were through the facility-based system. The CBS system also recorded an increase from 36.0% in 2014 to 92.0% in December 2016 for the number of counties that were reporting AFP. A CBS system is, therefore, a valuable complement to facility-based surveillance in insecure environments or where the population has limited access to facilities. Community-based surveillance systems also have the potential to identify cases of other infectious diseases of public health importance.

Use of a mobile application for Ebola contact tracing and monitoring in northern Sierra Leone: a proof-of-concept study

Background

The 2014–2016 Ebola epidemic in West Africa was the largest Ebola epidemic to date. Contact tracing was a core surveillance activity. Challenges with paper-based contact tracing systems include incomplete identification of contacts, delays in communication and response, loss of contact lists, inadequate data collection and transcription errors.

The aim of this study was to design and evaluate an electronic system for tracing contacts of Ebola cases in Port Loko District, Sierra Leone, and to compare this with the existing paper-based system. The electronic system featured data capture using a smartphone application, linked to an alert system to notify the District Ebola Response Centre of symptomatic contacts.

Methods

The intervention was a customised three-tier smartphone application developed using Dimagi’s CommCare platform known as the Ebola Contact Tracing application (ECT app). Eligible study participants were all 26 Contact Tracing Coordinators (CTCs) and 86 Contact Tracers (CTs) working in the 11 Chiefdoms of Port Loko District during the study period (April–August 2015). Case detection was from 13th April to 17th July 2015. The CTCs and their CTs were provided with smartphones installed with the ECT app which was used to conduct contact tracing activities. Completeness and timeliness of contact tracing using the app were compared with data from April 13th-June 7th 2015, when the standard paper-based system was used.

Results

For 25 laboratory-confirmed cases for whom paper-based contact tracing was conducted, data for only 39% of 408 contacts were returned to the District, and data were often incomplete. For 16 cases for whom app-based contact tracing was conducted, 63% of 556 contacts were recorded as having been visited on the app, and the median recorded duration from case confirmation to first contact visit was 70 h.

Conclusion

There were considerable challenges to conducting high-quality contact tracing in this setting using either the paper-based or the app-based system. However, the study demonstrated that it was possible to implement mobile health (mHealth) in this emergency setting. The app had the benefits of improved data completeness, storage and accuracy, but the challenges of using an app in this setting and epidemic context were substantial.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4354-z) contains supplementary material, which is available to authorized users.

Community-based surveillance: A scoping review

Background

Involving community members in identifying and reporting health events for public health surveillance purposes, an approach commonly described as community-based surveillance (CBS), is increasingly gaining interest. We conducted a scoping review to list terms and definitions used to characterize CBS, to identify and summarize available guidance and recommendations, and to map information on past and existing in-country CBS systems.

Methods

We searched eight bibliographic databases and screened the worldwide web for any document mentioning an approach in which community members both collected and reported information on health events from their community for public health surveillance. Two independent reviewers performed double blind screening and data collection, any discrepancy was solved through discussion and consensus.

Findings

From the 134 included documents, several terms and definitions for CBS were retrieved. Guidance and recommendations for CBS were scattered through seven major guides and sixteen additional documents. Seventy-nine unique CBS systems implemented since 1958 in 42 countries were identified, mostly implemented in low and lower-middle income countries (79%). The systems appeared as fragmented (81% covering a limited geographical area and 70% solely implemented in a rural setting), vertical (67% with a single scope of interest), and of limited duration (median of 6 years for ongoing systems and 2 years for ended systems). Collection of information was mostly performed by recruited community members (80%).

Interpretation

While CBS has already been implemented in many countries, standardization is still required on the term and processes to be used. Further research is needed to ensure CBS integrates effectively into the overall public health surveillance system.

Factors Influencing Community Event-based Surveillance: Lessons Learned from Pilot Implementation in Vietnam

Community event-based surveillance aims to enhance the early detection of emerging public health threats and thus build health security. The Ministry of Health of Vietnam launched a community event-based surveillance pilot program in 6 provinces to improve the early warning functions of the existing surveillance system. An evaluation of the pilot program took place in 2017 and 2018. Data from this evaluation were analyzed to determine which factors were associated with increased detection and reporting. Results show that a number of small, local events were detected and reported through community event-based surveillance, supporting the notion that it would also facilitate the rapid detection and reporting of potentially larger events or outbreaks. The study showed the value of supportive supervision and monitoring to sustain community health worker reporting and the importance of conducting evaluations for community event-based surveillance programs to identify barriers to effective implementation.

Novel surveillance methods for the control of Ebola virus disease

The unprecedented scale of the 2013-2016 West African Ebola virus disease (EVD) outbreak was in a large part due to failings in surveillance: contacts of confirmed cases were not systematically identified, monitored and diagnosed early, and new cases appearing in previously unaffected communities were similarly not rapidly identified, diagnosed and isolated. Over the course of this epidemic, traditional surveillance methods were strengthened and novel methods introduced. The wealth of experience gained, and the systems introduced in West Africa, should be used in future EVD outbreaks, as well as for other communicable diseases in the region and beyond.

The Effects of an Integrated Community Case Management Strategy on the Appropriate Treatment of Children and Child Mortality in Kono District, Sierra Leone: A Program Evaluation

Integrated community case management (iCCM) aims to reduce child mortality in areas with poor access to health care. iCCM was implemented in 2009 in Kono district, Sierra Leone, a postconflict area with high under-five mortality rates (U5MRs). We evaluated iCCM's impact and effects on child health using cluster surveys in 2010 (midterm) and 2013 (endline) to compare indicators on child mortality, coverage of appropriate treatment, timely access to care, quality of care, and recognition of community health workers (CHWs). The sample size was powered to detect a 28% decline in U5MR. Clusters were selected proportional to population size. All households were sampled to measure mortality and systematic random sampling was used to measure coverage in a subset of households. We used program data to evaluate utilization and access; 5,257 (2010) and 3,649 (2013) households were surveyed. U5MR did not change significantly (4.54 [95% confidence interval [CI]: 3.47-5.60] to 3.95 [95% CI: 3.06-4.83] deaths per 1,000 per month (P = 0.4)) though a relative change smaller than 28% could not be detected. CHWs were the first source of care for 52% (2010) and 50.9% (2013) of children. Coverage of appropriate treatment of fever by CHWs or peripheral health units increased from 45.5% [95% CI: 39.2-52.0] to 58.2% [95% CI: 50.5-65.5] (P = 0.01); changes for diarrhea and pneumonia were not significant. The continued reliance on the CHW as the first source of care and improved coverage for the appropriate treatment of fever support iCCM's role in Kono district.

"We and the nurses are now working with one voice": How community leaders and health committee members describe their role in Sierra Leone's Ebola response

Background

Across low-income settings, community volunteers and health committee members support the formal health system - both routinely and amid emergencies - by engaging in health services such as referrals and health education. During the 2014–2015 Ebola epidemic, emerging reports suggest that community engagement was instrumental in interrupting transmission. Nevertheless, literature regarding community volunteers’ roles during emergencies generally, and Ebola specifically, is scarce. This research outlines what this cadre of the workforce did, how they coped, and the facilitators and barriers they faced to providing care in Sierra Leone.

Methods

Thirteen focus group discussions (FGD) were conducted with community members (including members of Health Management Committees (HMC)) near the height of the Ebola epidemic in two districts of Sierra Leone: Bo and Kenema. Conducted in either Krio or Mende, each FGD lasted an average of two hours and was led by a trained moderator who was accompanied by a note taker. All FGDs were audio recorded, transcribed, and translated into English by the data collection team. Analysis followed a modified framework approach, which entailed coding (both inductive and deductive), arrangement of codes into themes, and drafting, distribution and discussion of analytic summaries across the study team.

Results

Community volunteers and HMC members described engaging in labor-related tasks (e.g. building isolation structures, digging graves) and administrative/community-outreach tasks (e.g. screening, contact tracing, and encouraging care seeking within facilities). Through their dual orientation as community members and as individuals linked to the health system, respondents described building community trust and support for Ebola prevention and treatment, while also enabling formal health workers to better understand and address people’s fears and needs. Community volunteers’ main concerns included inadequate communication with - and a sense of being forgotten by - the health system, negative perceptions of their role within their communities, and concerns regarding the amount and nature of their compensation.

Discussion & Conclusion

Respondents described commitment to supporting their health system and their communities during the Ebola crisis. The health system could more effectively harness the potential of local responders by recognizing community strengths and weaknesses, as well as community volunteers’ motivations and limitations. Clarifying the roles, responsibilities, and remuneration of health volunteers to the recipients themselves, facility-based staff, and the wider community will enable organizations that partner with health committees to bolster trust, manage expectations, and reinforce collaboration.

Community Event-Based Surveillance for Ebola Virus Disease in Sierra Leone: Implementation of a National-Level System During a Crisis

INTRODUCTION: There are few documented examples of community networks that have used unstructured information to support surveillance during a health emergency. In January 2015, the Ebola Response Consortium rapidly implemented community event-based surveillance for Ebola virus disease at a national scale in Sierra Leone.

METHODS: Community event based surveillance uses community health monitors in each community to provide an early warning system of events that are suggestive of Ebola virus disease transmission. The Ebola Response Consortium, a consortium of 15 nongovernmental organizations, applied a standardized procedure to implement community event-based surveillance across nine of the 14 districts. To evaluate system performance during the first six months of operation (March to August 2015), we conducted a process evaluation. We analyzed the production of alerts, conducted interviews with surveillance stakeholders and performed rapid evaluations of community health monitors to assess their knowledge and reported challenges.

RESULTS: The training and procurement of supplies was expected to begin in January 2015 and attain full scale by March 2015. We found several logistical challenges that delayed full implementation until June 2015 when the epidemic was past its peak. Community health monitors reported 9,131 alerts during this period. On average, 82% of community health monitors reported to their supervisor at least once per week. Most alerts (87%) reported by community health monitors were deaths unrelated to Ebola. During the rapid evaluations, the mean recall by community health monitors was three of the six trigger events. Implementation of the national system achieved scale, but three months later than anticipated.

DISCUSSION: Community event based surveillance generated consistent surveillance information during periods of no- to low-levels of transmission across districts. We interpret this to mean that community health monitors are an effective tool for generating useful, unstructured information at the village level. However, to maximize validity, the triggers require more training, may be too many in number, and need increased relevance to the context of the tail end of the epidemic.