Conceptualisation and implementation of integrated disease surveillance globally: a scoping review.

OBJECTIVES: The objective of this study was to examine the conceptualisation and operationalisation of Integrated Disease Surveillance (IDS) systems globally and the evidence for their effectiveness. Furthermore, to determine whether the recommendations made by Morgan et al. are supported by the evidence and what the evidence is to inform country development of IDS. STUDY DESIGN: The study incorporated a scoping review. METHODS: This review summarised evidence meeting the following inclusion criteria: Participants: any health sector; Concept: IDS; and Context: global. We searched Medline, Embase, and Epistemonikos for English publications between 1998 and 2022. Standard review methods were applied. A bespoke conceptual framework guided the narrative analysis. This scoping review is part of a research programme with three key elements, with the other studies being a survey of the International Association of National Public Health Institutes members on the current status of their disease surveillance systems and a deeper analysis and case studies of the surveillance systems in seven countries, to highlight the opportunities and challenges of integration. RESULTS: Eight reviews and five primary studies, which were assessed as being of low quality, were included, mostly examining IDS in Africa, the human sector, and communicable diseases. None reported on the effects on disease control or on the evolution of IDS during the COVID-19 pandemic. Descriptions of IDS and of integration varied. Prerequisites of effective IDS systems mostly related to the adequacy of core functions and resourcing requirements. Laws or regulations supporting system integration and data sharing were not addressed. The provision of core functions and resourcing requirements were described as inadequate, financing as non-sustainable, and governance as poor. Enablers included active data sharing, close cooperation between agencies, clear reporting channels, integration of vertical programs, increased staff training, and adopting mobile reporting. Whilst the conceptual framework for IDS and Morgan et al.'s proposed principles were to some extent reflected in the highlighted priorities for IDS in the literature, the evidence base remains weak. CONCLUSIONS: Available evidence is fragmented, incomplete, and of poor quality. The review found a lack of robust evaluation studies on the impact of IDS on disease control. Whilst a lack of evidence does not imply a lack of benefit or effect, it should signal the need to evaluate the process and impact of integration in the future development of surveillance systems. A common IDS definition and articulation of the parts that constitute an IDS system are needed. Further robust impact evaluations, as well as country reviews and evaluations of their IDS systems, are required to improve the evidence base.

Surveillance system integration: reporting the results of a global multicountry survey.

OBJECTIVES: Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs). STUDY DESIGN: This was a cross-sectional survey of NPHIs. METHODS: A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status. RESULTS: Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability. CONCLUSIONS: Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

The state of integrated disease surveillance in seven countries: a synthesis report.

OBJECTIVES: Integrated disease surveillance (IDS) offers the potential for better use of surveillance data to guide responses to public health threats. However, the extent of IDS implementation worldwide is unknown. This study sought to understand how IDS is operationalized, identify implementation challenges and barriers, and identify opportunities for development. STUDY DESIGN: Synthesis of qualitative studies undertaken in seven countries. METHODS: Thirty-four focus group discussions and 48 key informant interviews were undertaken in Pakistan, Mozambique, Malawi, Uganda, Sweden, Canada, and England, with data collection led by the respective national public health institutes. Data were thematically analysed using a conceptual framework that covered governance, system and structure, core functions, finance and resourcing requirements. Emerging themes were then synthesised across countries for comparisons. RESULTS: None of the countries studied had fully integrated surveillance systems. Surveillance was often fragmented, and the conceptualization of integration varied. Barriers and facilitators identified included: 1) the need for clarity of purpose to guide integration activities; 2) challenges arising from unclear or shared ownership; 3) incompatibility of existing IT systems and surveillance infrastructure; 4) workforce and skills requirements; 5) legal environment to facilitate data sharing between agencies; and 6) resourcing to drive integration. In countries dependent on external funding, the focus on single diseases limited integration and created parallel systems. CONCLUSIONS: A plurality of surveillance systems exists globally with varying levels of maturity. While development of an international framework and standards are urgently needed to guide integration efforts, these must be tailored to country contexts and guided by their overarching purpose.

Are schools drivers of COVID-19 infections-an analysis of outbreaks in Colorado, USA in 2020.

BACKGROUND: The impact of school closures/reopening on transmission of SARS-CoV-2 in the wider community remains contested. METHODS: Outbreak data from Colorado, USA (2020), alongside data on implemented public health measures were analyzed. RESULTS: There were three waves (n = 3169 outbreaks; 61 650 individuals). The first was led by healthcare settings, the second leisure/entertainment and the third workplaces followed by other settings where the trajectory was equally distributed amongst essential workplaces, non-essential workplaces, schools and non-essential healthcare.Non-acute healthcare, essential and non-essential workplace experienced more outbreaks compared to education, entertainment, large-group-living and social gatherings.Schools experienced 11% of identified outbreaks, yet involved just 4% of total cases. Conversely, adult-education outbreaks (2%) had disproportionately more cases (9%). CONCLUSION: Our findings suggest schools were not the key driver of the latest wave in infections. School re-opening coinciding with returning to work may have accounted for the parallel rise in outbreaks in those settings suggesting contact-points outside school being more likely to seed in-school outbreaks than contact points within school as the wave of outbreaks in all other settings occurred either prior to or simultaneously with the schools wave.School re-opening is a priority but requires mitigation measures to do so safely including staggering opening of different settings whilst maintaining low levels of community transmission.

A scoping review of the experience of implementing population testing for SARS-CoV-2.

OBJECTIVES: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) - also known as the coronavirus disease (COVID-19) - pandemic has led to the swift introduction of population testing programmes in many countries across the world, using testing modalities such as drive-through, walk-through, mobile and home visiting programmes. Here, we provide an overview of the literature describing the experience of implementing population testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). STUDY DESIGN: Scoping review. METHODS: We conducted a scoping review using Embase, Medline and the Cochrane library in addition to a grey literature search. We identified indicators relevant to process, quality and resource outcomes related to each testing modality. RESULTS: In total, 2999 titles were identified from the academic literature and the grey literature search, of which 22 were relevant. Most studies were from the USA and the Republic of Korea. Drive-through testing centres were the most common testing modality evaluated and these provided a rapid method of testing whilst minimising resource use. CONCLUSIONS: The evidence base for population testing lacks high quality studies, however, the literature provides evaluations of the advantages and limitations of different testing modalities. There is a need for robust evidence in this area to ensure that testing is deployed in a safe and effective manner in response to the COVID-19 pandemic.

The health risks of informal waste workers in the Kathmandu Valley: a cross-sectional survey.

OBJECTIVE: To describe the health and occupational risks of informal waste workers (IWWs) in the Kathmandu Valley and explore the factors associated with not using personal protective equipment (PPE). STUDY DESIGN: This is a cross-sectional survey of IWWs. METHODS: Data were collected on the health and occupational risks of adult IWWs working on waste sites in the Kathmandu Valley and in the adjacent Nuwakot district, Nepal, in November 2017, through convenience sampling. Using a standardized health assessment questionnaire, face-to-face interviews were undertaken to record sociodemographic data, indicators of general and occupational health, data on healthcare access and use, physical risks, perception of occupational risks and use of PPE. Associations between use of PPE and gender, age, education, country of origin, injury and perception of occupational risks were examined using multivariate logistic regression analyses. RESULTS: In 1278 surveyed IWWs, prevalent physical risks included injuries (66.2% in the previous 12 months), and the main reported symptoms were respiratory in nature (69.9% in the previous 3 months). Most prevalent injuries were glass cuts (44.4%) and metal cuts (43.9%). Less than half of the IWWs (46.8%) had been vaccinated against tetanus and 7.5% against hepatitis B. The work was considered as 'risky' by 72.5% of IWWs, but 67.6% did not use PPE. Non-use of PPE was independently associated with male gender (odds ratio [OR] 2.19; P < 0.001), Indian origin (OR 1.35; P = 0.018), older age (OR 2.97 for more than the age of 55 years; P = 0.007) and low perception of occupational risks (OR 2.41; P < 0.001). Low perception of occupational risk was associated with older age (55 + years) and the lack of receipt of information on the risks. CONCLUSIONS: IWWs are at increased risk of injury in their work, yet are poorly protected in relation to vaccine-preventable infections and workwear. The results suggest that information is important in relation to perception of occupational risk, which in turn is associated with the use of PPE. There is a need for policymakers and public health practitioners to have a robust understanding of the needs and vulnerabilities of this group, as well as identify effective interventions that can be taken to safeguard the health and welfare of IWWs.

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers.

Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.

The changing health priorities of earthquake response and implications for preparedness: a scoping review.

OBJECTIVES: Earthquakes have substantial impacts on mortality in low- and middle-income countries (LMIC). The academic evidence base to support Disaster Risk Reduction activities in LMIC settings is, however, limited. We sought to address this gap by identifying the health and healthcare impacts of earthquakes in LMICs and to identify the implications of these findings for future earthquake preparedness. STUDY DESIGN: Scoping review. METHODS: A scoping review was undertaken with systematic searches of indexed databases to identify relevant literature. Key study details, findings, recommendations or lessons learnt were extracted and analysed across individual earthquake events. Findings were categorised by time frame relative to earthquakes and linked to the disaster preparedness cycle, enabling a profile of health and healthcare impacts and implications for future preparedness to be established. RESULTS: Health services need to prepare for changing health priorities with a shift from initial treatment of earthquake-related injuries to more general health needs occurring within the first few weeks. Preparedness is required to address mental health and rehabilitation needs in the medium to longer term. Inequalities of the impact of earthquakes on health were noted in particular for women, children, the elderly, disabled and rural communities. The need to maintain access to essential services such as reproductive health and preventative health services were identified. Key preparedness actions include identification of appropriate leaders, planning and training of staff. Testing of plans was advocated within the literature with evidence that this is possible in LMIC settings. CONCLUSIONS: Whilst there are a range of health and healthcare impacts of earthquakes, common themes emerged in different settings and from different earthquake events. Preparedness of healthcare systems is essential and possible, in order to mitigate the adverse health impacts of earthquakes in LMIC settings. Preparedness is needed at the community, organisational and system levels.

The 2015 Nepal earthquake disaster: lessons learned one year on.

INTRODUCTION: The 2015 earthquake in Nepal killed over 8000 people, injured more than 21,000 and displaced a further 2 million. One year later, a national workshop was organized with various Nepali stakeholders involved in the response to the earthquake. The workshop provided participants an opportunity to reflect on their experiences and sought to learn lessons from the disaster. METHODS: One hundred and thirty-five participants took part and most had been directly involved in the earthquake response. They included representatives from the Ministry of Health, local and national government, the armed forces, non-governmental organizations, health practitioners, academics, and community representatives. Participants were divided into seven focus groups based around the following topics: water, sanitation and hygiene, hospital services, health and nutrition, education, shelter, policy and community. Facilitated group discussions were conducted in Nepalese and the key emerging themes are presented. RESULTS: Participants described a range of issues encountered, some specific to their area of expertize but also more general issues. These included logistics and supply chain challenges, leadership and coordination difficulties, impacts of the media as well as cultural beliefs on population behaviour post-disaster. Lessons identified included the need for community involvement at all stages of disaster response and preparedness, as well as the development of local leadership capabilities and community resilience. A 'disconnect' between disaster management policy and responses was observed, which may result in ineffective, poorly planned disaster response. CONCLUSION: Finding time and opportunity to reflect on and identify lessons from disaster response can be difficult but are fundamental to improving future disaster preparedness. The Nepal Earthquake National Workshop offered participants the space to do this. It garnered an overwhelming sense of wanting to do things better, of the need for a Nepal-centric approach and the need to learn the lessons of the past to improve disaster management for the future.

Barriers to evidence-based disaster management in Nepal: a qualitative study.

OBJECTIVES: Globally, the incidence of natural disasters is increasing with developing countries tending to be worst affected. Implementing best practices in disaster management that are evidence-based is essential in order to improve disaster resilience and response. This study explores the barriers to evidence-based disaster management encountered in Nepal. STUDY DESIGN: A qualitative study was conducted in Nepal involving interviews with key informants in the disaster management field. METHODS: Government officials, academics, programme managers, disaster management practitioners and policymakers involved in disaster management were purposively sampled and invited to interview. 11 agreed to participate and were interviewed. The face-to-face interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: The interviews uncovered population-level barriers such as contextual factors (e.g. poverty), local custom and culture, as well as community-level issues (e.g. level of engagement and understanding). System-level barriers included limited demand for, availability and accessibility of the evidence-base. The implementation of evidence was influenced by the configuration of the disaster management system and system processes. Political ownership and leadership is an essential determinant of practice. CONCLUSIONS: Several barriers to evidence-based practice in disaster management exist in Nepal. The relative influence of the different barriers varies with political determinants likely to have greater importance in countries such as Nepal where system governance and leadership is insufficiently developed. These issues affect a country's vulnerability to disasters and need to be addressed.

Redesign and commissioning of sexual health services in England - a qualitative study.

OBJECTIVES: Responsibility for the commissioning of sexual and reproductive health (SRH) services transferred from the National Health Service to local authorities in England in 2013. This transfer prompted many local authorities to undertake new procurements of these SRH services. This study was undertaken to capture some of the lessons learnt in order to inform future commissioning and system redesign. STUDY DESIGN: A qualitative study was carried out involving semi-structured interviews. METHODS: Interviews were conducted with 13 local authority sexual health commissioners in Yorkshire and the Humber from 11 interviews. Thematic analysis was used to identify themes from transcripts of the interviews with the 13 participants. RESULTS: Key themes identified were as follows: the challenge and complexity to those new to clinical commissioning; the prerequisites of robust infrastructural inputs to undertake the process, including technical expertise, a dependable project team, with clarity over the timescales and the budget; the requirement for good governance, stakeholder engagement and successful management of relationships with the latter; and the need to focus on the outcomes, aiming for value for money and improved system performance. CONCLUSIONS: Several key issues emerged from our study that significantly influenced the outcome of the redesign and commissioning process for sexual health services. An adapted model of the Donabedian evaluation framework was developed to provide a tool to inform future system redesign. Our model helps identify the key determinants for successful redesign in this context which is essential to both mitigate potential risks and maximize the likelihood of successful outcomes. Our model may have wider applications.