10 SURVEILLANCE

Surveillance is defined under the IHR as the systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for action. Annex 1 of the IHR outlines core capacities required for surveillance at local/primary, subnational and national public health response levels, including detection, reporting, notification, verification and collaboration activities.

To address the challenges highlighted by the COVID-19 pandemic and other past and current emergencies, the collaborative surveillance concept has been introduced as a core building block of the WHO Framework for Strengthening Global Architecture for Health Emergency Preparedness, Response, and Resilience (HEPR), which proposes key objectives and capabilities for strengthening public health intelligence for improved decision-making. Collaborative surveillance is defined as “the systematic strengthening of capacity and collaboration among diverse stakeholders, both within and beyond the health sector, with the ultimate goal of enhancing public health intelligence and improving evidence for decision making”. This concept promotes the strengthening of routine surveillance capacities (including public health and laboratory surveillance) and health systems monitoring, and collaboration between and beyond these systems to collectively support diverse surveillance objectives and decision-maker needs on a routine ongoing basis and toward health emergency prevention, preparedness, response and recovery.

Benchmark actions listed below are limited to areas related defined by the current JEE indicators (3rd edition):

  • D2.1. Earlier warning surveillance function
  • D2.2. Event verification and investigation; and
  • D2.3. Analysis and information sharing.

Wherever possible, countries should consider the full range of collaborative surveillance objectives, capacities, and subcapabilities in addition to those outlined here, as well as other related benchmarks, during the prioritization of actions.

IMPACT:

Coordinated surveillance systems that collectively address the full range of objectives for monitoring, detecting and responding to prioritized hazards and risks55. Strengthened public health intelligence for improved decision making through routine collaboration across key dimensions56.

MONITORING AND EVALUATION:

(1) Surveillance for locally prioritized hazards conducted according to international standards. (2) Regular analysis, dissemination and reporting of surveillance data.

Benchmark 10.1

Early warning surveillance systems are well established and functional

Objective To establish a well functional early warning surveillance system

01 NO CAPACITY

  1. National public health surveillance strategies, capacities and coordination mechanisms do not exist.

02 LIMITED CAPACITY

  1. Develop a national public health surveillance strategy, capacities and coordination mechanism based on IHR requirements and priority risks. *
  2. Identify priority events, diseases and conditions under surveillance based on an all hazards approach. *
  3. Designate a national public health authority to coordinate surveillance (dedicated unit or department) with surveillance focal persons at subnational and local levels. *
  4. Finalize operational plans and processes, including training and guidance. *
  5. Disseminate guidelines and SOPs for health and public health workers (e.g. clinicians, laboratorians, surveillance officers) to support detection and assessment of prioritized risks. *
  6. Map surveillance stakeholders to improve coordination, avoid duplication of efforts, and identify resources for management and control of priority diseases and risks, including human resources, equipment, digital tools and infrastructure. *
  7. Establish core indicator-based surveillance (IBS) and event-based surveillance (EBS) for priority case and event detection including priority diseases, and disseminate case definitions at national and subnational levels including: Establish health facility and laboratory-based systems for nationally notifiable diseases and conditions (including unusual events),Establish community-based surveillance with an emphasis on underserved areas/groups and vulnerable populations, in collaboration with community health worker (CHW)/community health volunteer (CHV) networks operating at the animal-human-environment interface. *
  8. Establish national level public health intelligence functions linked to response capacities. *
  9. Form a multisectoral country task force (with ToRs) to detect, verify and manage events and threats at the animal-human-environmental interface, following a One Health approach and bringing together relevant sectors at the national and subnational levels. *
  10. Establish monitoring and periodic evaluations/reviews of surveillance systems, including review of coverage and gaps for populations and geographic areas with increased vulnerability to prioritize community-based surveillance needs. *
  11. Orient public health surveillance team on the capacity levels of relevant sectors (e.g. animal health, environmental health).
  12. Coordinate and collaborate with public health surveillance teams from relevant sectors.

03 DEVELOPED CAPACITY

  1. Map cross-sectoral surveillance stakeholders and identify focal points for better data/information/intelligence exchange, coordination and collaboration. *
  2. Conduct multisectoral assessments of public health risks at the national level and match surveillance capacities to prioritized hazards. *
  3. Train health and public health workers (e.g. clinicians, laboratorians, surveillance officers) on SOPs for detecting and assessing prioritized risks.
  4. Develop strategies and mechanisms for cross-border surveillance, such as at points of entry, and regular data- and information-sharing between public health authorities in neighbouring countries. *
  5. Expand core IBS and EBS systems, extending coverage to all relevant public and private health services, and other relevant healthcare providers. *
  6. Establish immediate and weekly reporting mechanisms and feedback loops for reporting units, investigate and assess the reported cases or events with outbreak potential for public health response, link to laboratory results and share information with relevant sectors. *
  7. Conduct regular AAR/IAR of major events. *
  8. Establish and test complementary or more appropriate surveillance approaches to fill identified gaps for prioritized risks. *
  9. Digitize surveillance processes where appropriate, giving prioritization to points of data collection. *
  10. Train relevant workers (e.g. veterinarians, laboratorians, surveillance officers, etc.) on SOPs for detecting and assessing prioritized risks in relevant sectors.
  11. Coordinate and collaborate with the public health surveillance team including orientation to other sector capacities (animal health) at subnational level.
  12. Share information with public health decision-makers on any event that may impact health security.

04 DEMONSTRATED CAPACITY

  1. Critically evaluate performance of the constellation of surveillance systems and capacities, including effectiveness and efficiency in respective systems for achieving early warning objectives and driving timely decision-making against locally prioritized risks. Document and disseminate findings and apply recommendations to update and strengthen overall efficiency of strategies, systems and tools. *
  2. Establish decentralized coordination and technical capacities at subnational levels to enable more timely decision-making and response. *
  3. Extend training to all relevant health and public health workers (e.g. clinicians, laboratorians, surveillance officers, etc.) in SOPs for detecting and assessing prioritized risks.
  4. Establish community engagement and support communities to establish self-coordinated capacities and systems for community-centred detection, notification and response through integrated approaches between communities, civil societies, primary care and local government. *
  5. Integrate or collaborate with surveillance activities where appropriate through consolidation of systems, and by: Applying common/interoperable data platforms and standards, Routine exchange of data, information, intelligence and capacities between stakeholders, Conducting joint assessments, investigations and interventions, Strategic alignment of priorities and plans. *
  6. Extend the use of digital tools across surveillance systems and levels to automate routine data management and reporting processes, and enable greater linkage and interoperability between systems. *
  7. Incorporate contemporary and multidisciplinary insights on hazards, vulnerabilities and risks (e.g. multidimensional poverty index) to better interpret surveillance findings and complement early warning and response activities. *
  8. Review limitations of routine surveillance capacity to surge during emergencies, adjust where possible and preselect contingency tools to fill anticipated gaps. *
  9. Conduct data collection and both routine and ad hoc reporting at health facilities at a high level of quality. *
  10. Conduct joint operational research for the development and testing of surveillance best practices, tools and technologies, and innovative approaches, and translate findings into system improvements *
  11. Establish collaboration across key dimensions, ensuring that the exchange of data, information, intelligence and joint activities are designed and incentivised to satisfy mutual needs without overloading systems.
  12. Incorporate training considerations for relevant workers (e.g.veterinarians, laboratorians, surveillance officers, etc.) into SOPs for detecting and assessing prioritized risks in relevant sectors.

05 SUSTAINABLE CAPACITY

  1. Undertake systematic monitoring, evaluation and learning (as outlined in above steps) to continuously identify and correct limitations in routine systems. *
  2. Assess the flexibility of routine surveillance capacity to rapidly surge and adapt during large scale emergencies and plan and adjust where possible. *
  3. Establish and reinforce decentralized surveillance coordination and technical capacities at primary public health levels to enable local use of data for local decision-making and response. *
  4. Routinely apply surveillance findings together with information on hazards, vulnerabilities and risks for predicting and preemptively responding to emerging risks (even before the first cases). *
  5. Contribute to local, regional and global surveillance capacity through regional/international networks, support other countries to strengthento their surveillance system and participate in international initiatives to strengthen capacities globally. *
  6. Establish a mechanism to ensure continuous improvement in data quality at health facilities by monitoring, evaluating and adapting data collection and reporting of routine and ad hoc events. *
  7. Advance joint operational research for the development and testing of surveillance best practices, tools and technologies, and innovative approaches, and translate findings into system improvements *
  8. Reinforce collaboration across all key dimensions, ensuring that the exchange of data, information, intelligence and joint activities are designed and incentivised to satisfy mutual needs without overloading systems.
  9. Sustain contributions to surveillance capacity evaluations and support strategies and mechanisms to integrate and enhance collaboration.

Benchmark 10.2

Well-functioning event verification and investigation system is in place

Objective To establish a robust well functioning early warning, alert and response (EWAR) 40 capacity

01 NO CAPACITY

  1. Method, process or mechanisms for verifying and investigating detected events does not exist.

02 LIMITED CAPACITY

  1. Designate national focal points to prepare and coordinate EWAR capacities and undertake core public health intelligence functions. Establish ToRs to identify and document roles and responsibilities of relevant staff and stakeholders at all levels. *
  2. Prepare for EWAR implementation at national and subnational levels by assessing the capacity of routine surveillance systems, coordination mechanisms, laboratory support and linkage to response. *
  3. Identify existing surveillance data flows and how signal, event and alert data and information are managed at each level. *
  4. Establish tools and systems for standardized collection, management, reporting and sharing of EWAR-associated data. *
  5. Develop or adapt electronic tools for surveillance of public health and health security using unconventional data sources (e.g. traditional media, digital medias, social networks, etc.). *
  6. Link with and establish mechanisms to report alerts internationally and verify signals in line with IHR requirements. *
  7. Develop contextually appropriate methods and SOPs for each level's EWAR core functions and processes. *
  8. Establish multidisciplinary rapid response teams (RRTs) to undertake outbreak/ health emergency investigation and response *
  9. Review opportunities for multisectoral collaboration for the detection, verification and assessment of potential public health events.
  10. Develop and participate in cross-sectoral collaborations with health sector to exchange data, information and intelligence between One Health partners and conduct joint verification of signals, investigations and risk assessments of events related to zoonoses.

03 DEVELOPED CAPACITY

  1. Designate subnational focal points to coordinate and undertake core functions. *
  2. Establish rapid communication pathways between teams operating across levels and sectors. *
  3. Conduct training and activate EWAR capacities, systems and SOPs at national and subnational levels. *
  4. Digitize EWAR processes as a function of routine surveillance systems where appropriate. *
  5. Improve data flows and routine reporting mechanisms at all levels. *
  6. Interconnect systems with decision-making authorities and resourced capacity for preemptive (before the first case) and early action. Identify focal persons/units to receive event details and risk assessments. *
  7. Train public health workers and RRTs and provide adequate resources to undertake outbreak/public health investigations and responses for prioritized risks. *
  8. Develop and implement mechanisms for routine monitoring and periodic evaluation of core EWAR functions. *
  9. Monitor the performance of EWAR functions, systems and capacities across levels and update the EWAR as required. *
  10. Implement multisectoral communication and collaboration, such as routine exchange of data, information and intelligence between One Health partners, joint verification of signals, and investigations and risk assessments of events related to zoonoses

04 DEMONSTRATED CAPACITY

  1. Establish fully operational core functions at the national and subnational level to provide the timely triage, verification, risk assessment and characterization, investigation, and response to reported cases or events, as well as standardized collection, management, reporting and sharing of associated data. Identify limitations in systems and fill gaps where possible. *
  2. Extend use of digital tools across levels to automate routine data management and reporting processes where appropriate. *
  3. Incorporate contemporary and multidisciplinary insights on hazards, vulnerabilities and risks to complement early warning activities. *
  4. Reinforce outbreak/health emergency investigation and response capacities at national and subnational levels. *
  5. Establish systems that protect electronic tools from cyberattacks to secure sharing of critical information such as personal data, medical confidentiality and classified information. *
  6. Conduct SimEx/AAR/IAR (as relevant) to evaluate the performance of functions, systems and capacities across EWAR levels. *
  7. Document and disseminate SimEx/AAR/IAR findings (as relevant) and apply recommendations to strengthen overall strategies, systems and tools. *
  8. Increase collaboration between One Health partners including routine exchange of data and information, incorporation of trained personnel from multiple sectors in RRTs, and undertaking joint signal verification, alert generation, risk assessment of events, investigation and response to relevant alerts.

05 SUSTAINABLE CAPACITY

  1. Establish a mechanism to maintain that core functions and cross-sectoral collaboration are operating seamlessly at national and subnational levels. Identify limitations in EWAR systems and fill gaps where possible. *
  2. Conduct necessary training and activate complementary EWAR capacities, systems and SOPs at primary health level; ensuring functions are interconnected with local decision-making and response authorities to affect timely local action. *
  3. Document and share best practices nationally and internationally for peer-to-peer learning. *
  4. Reinforce collaboration across all key surveillance dimensions and ensure that the exchange of data, information, intelligence and joint surveillance activities satisfy mutual needs without overloading systems.

Benchmark 10.3

Surveillance data and information are systematically analysed and shared to inform decision making for action

Objective To conduct timely and systematic analysis and sharing of data and information and enhance evidence for decision making and action

01 NO CAPACITY

  1. Systematic analyses of disease surveillance data for action not conducted or extended delays exist precluding timely action.

02 LIMITED CAPACITY

  1. Review national capacities to undertake analyses of surveillance data. *
  2. Develop a training package for data management data collation, analysis, trend analysis and developing reports or weekly surveillance bulletins. *
  3. Develop and disseminate guidelines and procedures to assess risks. *
  4. Produce ad hoc analysis reports of outbreaks or other public health events based on needs or emerging events and disseminate from the national level. *
  5. Establish reporting standards and identify pathways for informing decision-making and response authorities of surveillance findings, as well as broader dissemination. *
  6. Map cross-sectoral surveillance stakeholders and identify focal points for coordination, collaboration and the exchange of relevant data, information and intelligence *

03 DEVELOPED CAPACITY

  1. Conduct training on data analysis and report development at national and subnational levels. *
  2. Conduct annual or monthly analysis of surveillance data for continuous monitoring of events of potential concern for public health and health security, including routine trend analyses and data quality assessment at national level. *
  3. Establish standards and training to integrate data and information sources from multisectoral partners. *
  4. Establish feedback loops for sharing analytic results, from national to subnational levels at a minimum and across sectors. *
  5. Develop standards and training for quality data collection for routine and ad hoc reporting of unusual or unexpected events at healthcare facility level. *
  6. Develop standards and training for analysis of data by multiple sectors to support joint risk assessment.

04 DEMONSTRATED CAPACITY

  1. Develop or reinforce standards, content and format for epidemiological bulletins for national and subnational levels and weekly epidemiological reports on priority diseases and ad hoc events, including analysis and risk assessment disseminated at all levels. *
  2. Develop or reinforce standards and training to analyse data from multiple information sources across sectors available at all levels. *
  3. Establish or reinforce capacity to routinely triangulate data from multiple health information and surveillance systems, including from relevant sectors. *
  4. Establish or reinforce existing real time analytical information sharing, including data visualizations and dashboards. *
  5. Develop and implement a mechanism for M&E of timely data analysis and reporting for prioritized hazards under surveillance at national and subnational levels *
  6. Train animal and environmental sector stakeholders in analysis methods contributing to cross-sectoral risk assessment.

05 SUSTAINABLE CAPACITY

  1. Establish or reinforce dedicated analytic teams at national, subnational and primary levels, to link sectors and contextualize epidemiological information across multiple disciplines. *
  2. Reinforce analytical functions of common/interoperable electronic platforms and establish default automated analysis at all EWAR levels. *
  3. Establish or reinforce advanced analytical and modelling capacities at the national level. *
  4. Develop or reinforce guidelines, standards, norms and quality requirements, as well as regularly review and update training packages for analysis and risk assessment based on lessons learned. *
  5. Routinely contribute, from multisectoral stakeholders, to joint analysis, risk assessment (both ad hoc and routine), reporting and the generation of recommendations

* Participation and contribution of other sectors to action.

Tools