The global emergence of the human immunodeficiency virus and novel influenza strains raised awareness of the importance of global health surveillance in the latter part of the twentieth century. Several events in the first decade of the twenty-first century highlighted global shared interests in and vulnerability to infectious diseases. The use of anthrax spores by terrorists in 2001 raised awareness of the importance of public health surveillance for national security. The 2003 SARS epidemic, the re-emergence of a panzootic of avian influenza A H5N1 in 2005, and the unexpected emergence of pandemic H1N1 in North America in 2009 all highlighted the importance of shared global responsibility for disease surveillance and control (1,2). SARS, in particular, changed people’s perceptions of the world’s collective economic vulnerability to epidemic shocks in 2003.
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Global public health surveillance is critical for identifying and preventing emerging and reemerging infectious and noncommunicable diseases, which account for the majority of disease burdens, even in the poorest countries. It should provide timely health information, so governments have the information they need to fight epidemics or plan for the future. The development and maintenance of surveillance systems have effectively addressed several public health issues. Smallpox, for example, was eradicated through a shift in strategy from mass vaccination to surveillance with a rapid response (3). An integrated surveillance system effectively covers the world in the poliomyelitis eradication campaign, which channels specimens quickly to genotyping within days to weeks (4).
Disease surveillance and response are the responsibility of individual countries. The International Health Regulations (IHR), the most important and only binding international agreement on disease control, were revised in 2005 to include additional infectious diseases and to extend regulation to other public health events of global concern (5,6). IHR 2005 shifts the emphasis from border control to detection and management at the source, requiring countries to document their capacity for detection, verification, and response within borders (7). The regulations require countries to report public health events of international concern to the World Health Organization (WHO), which then disseminates the information to other countries as needed.
In several ways, global health surveillance and routine surveillance in low-resource countries differ from surveillance in industrialized countries:
More must be done with fewer resources.
Strengthening surveillance is more difficult.
Sustainability is more difficult.
This report proposes a vision for global health surveillance, identifies challenges and opportunities, and makes recommendations for achieving the vision. The topic was recognized by CDC leadership as one of six major domains that the public health community must address to advance public health surveillance in the twenty-first century. The six topics were discussed by CDC workgroups formed as part of the 2009 Surveillance Consultation to promote public health surveillance to meet ongoing and new challenges (8). This report is based on workgroup discussions and intends to continue talks with the public health community to develop a shared vision for public health surveillance in the twenty-first century.
A single statement could not adequately capture the vision required for global health surveillance. Instead, two vision statements are required: one that reflects the net global effect of quality surveillance and another that transfers responsibility for managing public health surveillance that meets each country’s health goals to the national level.
A globally connected network of public health surveillance systems that optimizes disease prevention and health promotion.
A fully operational, efficient set of national public health surveillance systems that protect the nation’s public health and provide timely information to guide public health action for each country.
Realizing these visions for effective global health surveillance will necessitate overcoming several obstacles. These include a lack of commitment and leadership (9,10); insufficient administration of priority conditions; poor standardization and interoperability of surveillance systems; a lack of mechanisms for or devotion to effective partnerships; and a lack of research, innovation, and effective acceptance of technology in global health surveillance.
Leadership is the first and most important requirement for achieving the two interdependent visions. Strong leadership is required to support the transition to more fully coordinated, interoperable, and sustainable global public health surveillance systems. Because of the variety of national and international partners who must work in a mutually reinforcing fashion in low-resource settings, the challenges and service leadership requirements are more difficult. Donor-driven priorities or global concerns in a country frequently result in multiple, vertical, disease-specific surveillance programs with separate information systems, personnel, vehicles, and office space at each administrative level of the country (11). Integration of similar surveillance functions across multiple diseases can result in increased efficiencies, but only if resources are preserved, and engaged leadership for surveillance and health situation awareness is recognized as a major governmental responsibility (12). Public health surveillance and health information systems typically necessitate significant financial investments. To create an enabling environment for management, commitment and leadership are required.
Priority Condition Surveillance
Addressing the imbalance in coverage of surveillance systems for critical health problems is a crucial challenge in moving toward the proposed vision for global health surveillance. In many low-resource settings, surveillance resources are made available through targeted global initiatives and global priorities (e.g., through the Global Fund for AIDS, Tuberculosis, and Malaria). In contrast, other health priorities frequently go unaddressed (13). Even in the poorest countries with the highest infectious disease burden, chronic, noncommunicable diseases have become the leading causes of death; as a result, surveillance for tobacco use, obesity, and other noninfectious conditions has become a pressing priority for public health surveillance. Emerging epidemics of cardiovascular disease, cancer, and motor vehicle injury are not being tracked systematically in many countries, so even the most critical information for public health action — the rates and causes of death in the population — is being estimated haphazardly based on estimates from other countries. It is critical to ensure that surveillance systems result in improved health security for industrialized nations and improved health for people in the poorest countries (1,14).
Interoperability and standardization
Surveillance systems are frequently set up with little regard for the information system and surveillance architecture in which they must operate. One international consultant’s idiosyncratic experience may result in a recommendation of a surveillance approach, data definitions and formats, laboratory methods recommended, or software used that is not optimal for the country. Accepting assistance from international partners may also obligate the government to purchase or utilize specific equipment or to adopt surveillance approaches that complicate or contribute to the fragmentation of the country’s surveillance and health protection enterprise (15). The global establishment of detailed informatics standards for surveillance would allow countries to tailor those standards to their epidemiology, disease control, and health promotion priorities (12). Furthermore, consensus standards are required that extend beyond basic surveillance science and informatics to ethical concerns, data sharing, privacy and confidentiality, and human subjects’ protection (16,17).
In many countries, the expansion of information and communication technology in recent decades has barely penetrated the domain of public health surveillance. The opportunity to use new technology for management is obvious. However, the coordination and trusted curation required to ensure efficient identification of best global practices, harmonization, and standardization is lacking in the development and implementation of these technologies. Countries would be left to independently assess and experiment with methods to incorporate new technologies into their national surveillance programs if there was no coordinated effort to identify best practices and share them with all nations.
Collaborations and Resources
These challenges can only be met through energized, highly effective, and ‘joined up’ partnerships between low-resource countries and the various international organizations that provide surveillance support. The multiple demands of partners and networks that assist a specific type of surveillance can strain emerging countries’ understaffed and underequipped ministries of health and surveillance units (18). The complexity of managing the national surveillance enterprise in many low-resource countries is increased by fragmented assistance and multiple international partners with different programs, schedules, funding streams, and monitoring requirements (19).
To address such challenges, the 2005 Paris Declaration for Aid Effectiveness promotes country ownership of programs, use of country systems, and development of and adherence to global consensus standards to make improved performance more feasible for emerging countries (12). Organizational innovation and commitment are needed to allow various stakeholders in the public health surveillance environment to begin operating in a more harmonized and aligned fashion.
The human resources necessary to perform surveillance activities are at a premium in developing countries. Health officials in developing countries might find it difficult to fill key technical positions (e.g., laboratory technicians and health information systems staff) because few applicants have the necessary skills. Equipment shortages also constrain surveillance. The ability develop country health officials to provide accurate disease information is compromised further by their frequent lack of clear and precise diagnostic tests that they can perform themselves or ready access to functioning laboratories (20). As a result, they have difficulty making appropriate decisions about disease-control measures and might waste valuable resources (e.g., antibiotics and vaccines). Few developing countries have independent public health laboratories. Therefore, testing to confirm outbreaks must compete with testing to support patient-care decisions.
Increased attention and resources, technological advances, and international policies promoting disease control and surveillance can help improve global public health surveillance.
WHO overhauled IHR in 2005 (5,6). For the first time, IHR explicitly required each signatory to ensure the development of capacity at the national level to detect aberrations in the health status of all segments of the population within its jurisdiction. In addition, they required the ability to investigate, assess the threat, and respond accordingly, including rapid disclosure of known and suspected threats. This revolutionary global health pact elevates public health surveillance, response, and transparent reporting to a new level of international diplomacy and standards for normative behavior in the health information of a national population. IHR 2005 sets a new bar for surveillance system performance that will encourage surveillance authorities in low-resource countries and their national and international partners to substantially strengthen surveillance programs in every country by the end of 2012 when the new IHR requires the achievement of new global surveillance capacity standards (7). The United States can support and highlight surveillance requirements articulated in IHR 2005 in international forums (e.g., meetings of the World Health Assembly and the United Nations General Assembly) and can dedicate resources to countries willing to commit their resources (including the time and attention of leaders) to truly establishing the surveillance and response capacities required by the IHR 2005. Technical agencies like CDC can provide crosscutting technical support to partner countries eager to progress in this area.
Partnerships and Resources
An increasing number of organizations are providing technical and financial support for improved public health surveillance. WHO provides overall global leadership on public health surveillance (21,22). Other United Nations agencies, the World Bank, and other international development banks support disease prevention programs in low-resource countries and increasingly underwrite surveillance activities (20). Since 2000, several private or quasi-private global health organizations have become major supporters of global health, including surveillance activities (23). Approximately 100 Global Health Partnerships founded in the past include surveillance components for diseases of special interest (23).
Global initiatives that support surveillance for one particular global health priority can be encouraged or required to do so in a fashion that reinforces and contributes to international norms and standards. These initiatives enable low-resource countries to launch or extend their national strategies and systems to conduct surveillance for their health priorities. In particular, international disease elimination or eradication programs can help develop or reinforce the infrastructure needed for other national surveillance systems and requirements. These programs often have considerable resources, and integrating surveillance and control efforts where these are a natural fit can improve overall surveillance (24,25). Surveillance systems for the eradication of polio, guinea worm, malaria, and onchocerciasis have helped contribute to the strengthening of other basic surveillance systems and health-situation awareness in the most remote and challenging areas.
Technical Standards Development and Interoperability
Adopting the same norms, rules, and processes (e.g., data standards, standardized data dictionaries, data interfaces, and software development methods) promotes the ability to link data across surveillance programs and is easier for healthcare workers and public health surveillance workers to use. WHO has produced standardized case definitions for surveillance. The Health Metrics Network has developed a conceptual Technical Framework for Health Information Systems at a national level that locates management within a larger enterprise architecture (26,27); WHO promotes an approach to improve overall national public health surveillance by streamlining resources and coordinating surveillance functions at all levels of the health system. It attempts to provide countries with a framework to produce designs that are effective, efficient, and sustainable and to organize all public health surveillance activities into a common public service (28). Generally, moving stepwise toward standards-based interoperable systems is most feasible rather than attempting comprehensive surveillance integration initiatives simultaneously (18).
Organizations and an increasing number of networks operate to support, coordinate and harmonize surveillance. These networks can be important and useful sources of information, technical assistance, mentoring, and tools for surveillance programs in low-resource settings. As new resources and partners become available, developing plans for coordinating work is important for keeping surveillance as simple and sustainable as possible.
Technology in Global Health Settings
New communication and information technologies have the potential to enhance surveillance and health promotion in global health settings. Mobile phone handsets and networks have penetrated the poorest and most peripheral populations (29). The Internet continues to increase in scope and capacity globally. Health surveys can be conducted on handheld computing devices with global positioning system capacity, which has resulted in improved accuracy, sampling, supervision, and timeliness of analysis and reporting (30,31). Laboratory testing technology has evolved so that new assays can be implemented in simpler, usable formats in environments with weak infrastructures (32,33). Initiatives, such as the Grand Challenges in Global Health (34), promise to continue to spin off new laboratory tools to support surveillance in areas lacking laboratory capacity. As new technologies become available, it will be important to systematically and transparently identify and curate best global practices and harmonize and standardize the procedures recommended for low-resource settings.
Public health surveillance plays a critical role in mobilizing and targeting sufficient resources toward health impact goals, especially in low-resource settings. However, the quality of management in these countries is limited by several factors that should be addressed. More training is needed for clinical, laboratory, informatics, and public health surveillance officers to implement the most promising practices and uses of technology. The design of surveillance systems needs to be appropriate for each country while conforming to standards for global health surveillance. Surveillance systems should span the full spectrum of public health problems (i.e., infectious, chronic, injury, and environmental) corresponding to each country’s disease burden.
During a global health volunteer trip, you identified the need for a disease surveillance program targeting a preventable disease within a global population. You would like to create awareness about this need and propose a solution.
Select a preventable disease affecting a population and write a persuasive for the USAID.gov blog proposing a disease surveillance program.
Introduce the topic and include a thesis statement (1 paragraph)
Describe the preventable disease and population affected by the disease (1-2 paragraphs)
Propose methods for a disease surveillance program within the population (up to 1 page)
Suggest global health organizations that would be suited to launch the program (1-2 paragraphs)
Explain how the program would be communicated to healthcare providers and communities (1-2 paragraphs)
This should be in APA format. Information should be supported by evidence from professional sources, published within the past five years.