Global Health Surveillance
Corresponding author: Michael St. Louis, MD, Center for Global Health, CDC, Atlanta, Georgia, USA 30333. Telephone: 404-639-1635; Fax: 404-639-4268; E-mail: MStLouis@cdc.gov
Awareness of the importance of global health surveillance increased in the latter part of the 20th century with the global emergence of human immunodeficiency virus and novel strains of influenza. In the first decade of the 21st century, several events further highlighted global shared interests in and vulnerability to infectious diseases. Bioterrorist use of anthrax spores in 2001 raised awareness of the value of public health surveillance for national security. The epidemic of severe acute respiratory syndrome (SARS) in 2003, re-emergence of a panzootic of avian influenza A H5N1 in 2005, and the sudden emergence of pandemic H1N1 in North America in 2009 all highlighted the importance of shared global responsibility for surveillance and disease control (1,2). In particular, in 2003, SARS precipitated changes in awareness of the world's collective economic vulnerability to epidemic shocks.
Global public health surveillance is critical for the identification and prevention of emerging and reemerging diseases, both for infectious and noncommunicable diseases that account for the greatest burden of diseases, even in very poor countries. It should provide health information in a timely manner so that countries have the information that they need to fight epidemics now or to plan for the future. Several public health problems have been addressed effectively by the development and maintenance of surveillance systems. One example is smallpox, which was eradicated through a switch in strategy from mass vaccination to surveillance with rapid response (3). In the poliomyelitis eradication campaign, the world is covered effectively by an integrated surveillance system that channels specimens rapidly to genotyping within days to weeks (4).
Individual countries are responsible for disease surveillance and response. The most important and only binding international agreement on disease control is the International Health Regulations (IHR), which was revised in 2005 to include additional infectious diseases and to extend regulation to other public health events of international concern (5,6). IHR 2005 further shifts the focus from control at borders to detection and control at the sources and requires countries to document capacity for detection, verification, and response within borders (7). The regulations require countries that identify public health events of international concern to report to the World Health Organization (WHO), which disseminates the information, as needed, to other countries.
Global health surveillance and routine surveillance in low-resource countries differ from surveillance in industrialized countries in several ways: 1) more must be done with less, 2) strengthening surveillance is more complicated, and 3) sustainability is more challenging. This report proposes a vision for global health surveillance, identifies challenges and opportunities, and suggests approaches to attain the vision. The topic was identified by CDC leadership as one of six major domains that must be addressed by the public health community to advance public health surveillance in the 21st century. The six topics were discussed by CDC workgroups that were convened as part of the 2009 Surveillance Consultation to advance public health surveillance to meet continuing and new challenges (8). This report is based on workgroup discussions and is intended to continue the conversations with the public health community for a shared vision for public health surveillance in the 21st century.
A single statement could not adequately encompass the needed vision for global health surveillance. Instead, two vision statements are needed: one that reflects the net global effect of quality surveillance and a second that conveys to the national level the responsibility for managing public health surveillance that meets the health goals of each country.
For the world: A globally connected network of public health surveillance systems that optimizes disease prevention and health promotion.
For each nation: A fully functioning, efficient set of national public health surveillance systems that protect the nation's public health and provides timely information to guide public health action.
Realizing these visions for effective surveillance for global health threats will require meeting several challenging. These include a need for greater commitment and leadership (9,10); inadequate surveillance of priority conditions; inadequate standardization and interoperability of surveillance systems; insufficient mechanisms for or commitment to effective partnerships; and insufficient research, innovation, and effective acceptance of technology into global health surveillance.
Leadership is the first and most essential requirement for reaching the two interdependent visions. Strong leadership is required to support movement toward more fully coordinated, interoperable, sustainable global public heath surveillance systems. In low-resource settings, the challenges and service leadership requirements are more challenging because of the range of national and international partners that need to work in a mutually reinforcing fashion. Donor-driven priorities or international concerns in a country often result in multiple, vertical, disease-specific surveillance programs that use separate information systems, personnel, vehicles, and office space at every administrative level of the country (11). Integration of similar surveillance functions across multiple diseases can lead to greater efficiencies, but only if resources are maintained and if engaged leadership for surveillance and health situation awareness is recognized as a major governmental responsibility (12). Public health surveillance and health information systems usually require important financial commitments. Commitment and leadership is essential to create an enabling environment for surveillance.
Surveillance of Priority Conditions
A critical challenge in moving toward the proposed vision for global health surveillance is to address the imbalance in coverage of surveillance systems for critical health problems. In many low-resource settings, resources for surveillance are made available on the basis of targeted global initiatives and global priorities (e.g., through the Global Fund for AIDS, TB, and Malaria), whereas other health priorities often go unaddressed (13). Even among the poorest countries with the highest infectious disease burden, the leading causes of death have become chronic, noncommunicable diseases; as a result, surveillance for tobacco use, obesity, and other noninfectious conditions also become pressing priorities for public health surveillance. Emerging epidemics of cardiovascular disease, cancer, and motor vehicle injury are not monitored systematically in many countries, so even the most essential information for public health action — the rates and causes of death in the population — are estimated loosely based on estimates from other countries. Ensuring that surveillance systems result not only in enhanced health security for industrialized nations but also improved health of persons in the poorest countries is essential (1,14).
Standardization and Interoperability
Surveillance systems often are set up without due diligence for the information system and surveillance architecture in which they need to operate. The idiosyncratic experience of one international consultant might result in a recommendation of a surveillance approach, data definitions and formats, laboratory methods recommended, or software used that is mismatched to what would be optimal for the country. In addition, accepting assistance from international partners might obligate the country to purchase or use certain equipment or to adopt approaches to surveillance that complicate or contribute to fragmenting the surveillance and health protection enterprise in the country (15). The establishment of detailed informatics standards for surveillance at the global level would provide countries with the opportunity to adapt those standards to each country's epidemiology, disease control, and health promotion priorities (12). Furthermore, consensus standards that are needed go beyond basic surveillance science and informatics and extend to ethical concerns, data sharing, privacy and confidentiality, and human subjects protection (16,17).
The expansion of information and communication technology in recent decades has barely penetrated the domain of public health surveillance in many countries. The potential for harnessing new technology for surveillance is evident. However, development and implementation of these technologies lacks the coordination and trusted curation needed to ensure efficient identification of best global practices, harmonization, and standardization. Without a coordinated effort to identify best practices and share them with all nations, countries would be left to independently assess and experiment with methods to incorporate the new technologies into their national surveillance programs.
Partnerships and Resources
These challenges can only be addressed by energized, highly effective, and 'joined up' partnerships among low-resource countries and the diverse international organizations that provide support for surveillance. The multiple demands of partners and networks that provide assistance for a specific type of surveillance can strain understaffed and underequipped ministries of health and surveillance units in poor countries (18). The complexity of managing the national enterprise of surveillance 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 consensus global standards to make improved performance more feasible for poor 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 of developing country health officials to provide accurate disease information is compromised further by their frequent lack of clear and accurate 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, advances in technology, 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 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 strengthen surveillance programs in every country substantially by the end of 2012, when the new IHR requires 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 own 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/or 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 also provide support to disease prevention programs in low-resource countries and increasingly underwrite surveillance activities (20). Beginning around 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 own 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 eradication of polio, guinea worm, malaria, and onchocerciasis have helped contribute to strengthening of other basic surveillance systems and to health-situation awareness in the most remote and challenging areas.
Technical Standards Development and Interoperability
Adoption of 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 health-care workers and public health surveillance workers to use. WHO has produced standardized case definitions for surveillance, and the Health Metrics Network has developed a conceptual Technical Framework for Health Information Systems at a national level that locates surveillance 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 systems that are effective, efficient, and sustainable and to organize all public health surveillance activities into a common public service (28). In general, it is probably most feasible to move stepwise toward standards-based interoperable systems rather than attempting comprehensive surveillance integration initiative all at once (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 to 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 formats that are usable 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 that have lacked 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 practices recommended for low-resource settings.
Public health surveillance plays a critical role in mobilizing and targeting sufficient resources toward health impact goals, and this is especially true in low-resource settings. However, the quality of surveillance 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 burden of disease in each country.
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