The Challenges of Integrated Surveillance for National Public Health Institutes during the COVID-19 Pandemic

The session offered a panel discussion featuring surveillance experts from Pakistan's National Institute of Health, Mozambique's Instituto Nacional de Saúde, and the U.S. Centers for Disease Control and Prevention, moderated by the World Health Organization's Health Emergencies Program. The following paragraphs offer a summary of the contribution of the moderator and of each panelist.

Dr. Oliver Morgan, Director of Pandemic and Epidemic Intelligence Systems, Health Emergencies Programme, World Health Organization

The essence of surveillance is to monitor the epidemiology of diseases and identify outbreaks and new pathogens. The origins of disease surveillance can be traced back to the early 1850s when John Snow investigated a cholera outbreak in London. His investigation marked the beginning of epidemiological surveillance of infectious diseases. Public health surveillance evolved over time with major changes in the way it was conducted. 

In the 1950s, American epidemiologist Alexander Langmuir connected, for the first time, surveillance system data with public health action on the ground during the eradication of polio in the United States. This was the starting point of the integration and the response of modern public health surveillance, going from a passive approach of collecting statistical summaries to an intelligence process to inform disease control measures on the ground.

In the 1990s, the establishment of ProMed changed the architecture of global health surveillance. Through emails, ProMed encouraged people working in public health to share information and data, therefore introducing the participation of non-governmental sources. Around the same time, in 1994, WHO established a disease intelligence unit after a plague outbreak in India, with the objective of detecting occurrences of diseases as quickly as possible and responding at a global level. 

Even as integrated disease surveillance systems further evolved in the past few years, stronger systems are yet to be built. The WHO Hub for Pandemic and Epidemic Intelligence in Berlin is working to develop the future surveillance system with better data, analytics and decisions. 

Dr. Jennifer Adjemian, Acting Director, Division of Health Informatics and Surveillance, U.S. Centers for Disease Control and Prevention

In the United States, the main national surveillance programs include the National Notifiable Diseases Surveillance System, which list 120 conditions immediately reportable to the U.S. Centers for Disease Control and Prevention (CDC) when a case is identified, and the National Syndromic Surveillance Program, through which U.S. CDC receives emergency department data from over 70% of hospitals in the U.S. within 24 to 48 hours of the visit occurring. They provide a variety of data elements that allow CDC to use machine learning and other analytic tools to be able to rapidly identify public health events of concern. In addition, U.S. CDC works to actively bring in mortality data and commercial laboratory data.

U.S. CDC’s main challenge stems from the U.S. federated system of government, under which each jurisdiction at state and local level collects data for different purposes using different approaches. U.S. CDC does not have the authority to directly receive data without data use agreements set up with each separate jurisdiction. U.S. CDC tries to encourage standardized submission of data electronically, but data is still very much siloed by state and condition. It makes it difficult for CDC to have a national aggregated picture of surveillance. A lot of manual work is needed in order to clean the data and conduct analyses. 

COVID-19 has brought U.S. CDC in a new era of renewed motivation to modernize its approach to data and integrated analytics. U.S. CDC has now the visibility, resources and support to make major changes and overcome the issues that we had to contend with during the COVID-19 pandemic. Dr. Adjemian is cautiously optimistic that U.S. CDC is moving in the right direction. The key to being successful, she said, is making sure that the data is tied back to public health action at the local level. 

Muhammad Khan, head of the Transformation and Excellence Centre for Health (TECH) and National Health Datacenter, Pakistan National Institute of Health

The COVID-19 pandemic exposed structural weaknesses in Pakistan’s surveillance capacity and governance. Disease surveillance had not been a priority in the past due to a lack of understanding or interest of decision makers. Before the pandemic, Pakistan was already facing an important shortage of healthcare providers, with less than 1,000 physicians per million people. Most local health care facilities had no functional healthcare system and administrative infrastructure. The country was completely unprepared for a pandemic. Diagnostic testing capacity, protective equipment, contact tracing and quarantine capacity, and technical expertise and SOPs were inadequate.

Another big challenge was the 18^th amendment to the Pakistani constitution, which empowers provinces to manage their own health care delivery system. Fragmented surveillance systems operate in silos, which complicated the task of the National Institute of Health (NIH) in coordinating the national surveillance and response to COVID-19. To address these concerns, NIH established a National Command and Operations Center (NCOC). The NCOC helped reduce gaps in coordination at all levels and bring in and combine data from all over Pakistan. 

Strong, reliable systems were also developed, such as the national immunization system used for COVID-19 and other diseases like polio, and an inventory management system used to track essential resources like hospital beds and oxygen availability. Decisions about lockdowns and other restrictions were all based on data from digitized systems. NIH also established a National Health Data Center with the aim to bring all health data under one roof. Finally, NIH is also developing a National Health Decision Support System, to tie all these data streams together and use artificial intelligence and business intelligence tools to generate alerts and forward the results to the decision makers in the form of a consolidated dashboard. Muhammad Khan said NIH is hoping to have ultimately every laboratory, hospital, and other health facilities connected digitally. In order to get quality data from the subnational level, he added, the country needs to strengthen its workforce.

Dr. Jose Paulo Langa, Head of the Surveillance Department, Instituto Nacional de Saúde, Mozambique

As a low-income country, Mozambique has experienced weaknesses in its surveillance system while addressing the COVID-19 pandemic. But those difficulties have also presented opportunities to develop a stronger disease surveillance system. Before the outbreak, the Institute Nacional de Saúde (INS) was only using surveillance sources from the health sector. During the pandemic, the institute started collecting data from other sectors like telecommunications to help trace cases. INS also identified issues with data integration, especially in sectors other than health, and is now trying to increase cross-sectoral collaboration for data sharing. 

INS also encountered data transparency issues linked to the lack of preparedness of its surveillance system. The COVID-19 pandemic has shown that immigration data are important to pandemic surveillance. However, Mozambique’s immigration service was managing data differently than INS because of its paramilitary nature. Researchers had to figure out what kind of data was required for disease surveillance. The issue provided an opportunity for further developing the health observation platform, which analyzes data from other sectors and produces an analysis used for disease surveillance. 

Since the start of the COVID-19 outbreak, Mozambique has developed a multidisciplinary approach for surveillance at the national level. INS’ objective is now to apply this approach to the local level and improve data collection capacity. 

Quentin Sandifer, Strategic Adviser to the IANPHI Executive Board

IANPHI, in collaboration with the WHO Hub for Pandemic and Epidemic Intelligence and Germany’s Robert Koch Institute is undertaking a project with funding from the Bill & Melinda Gates Foundation, which aims to understand integrated disease surveillance from the perspective of national public health institutes through four activities. IANPHI will conduct a rapid review of the available literature and survey its members. Then IANPHI will undertake deep dives in selected countries (low and high income). The fourth work stream will be a collaboration between IANPHI and Resolve to Save Lives. The analysis and report are expected to be completed by early October. IANPHI will meet up with partner agencies to share our findings.

Writers: Marie Deveaux, Liza Thadani, Sarah Bayle. Editors: Marie Deveaux, Ellen Whitney