Finding the fragments: community-based epidemic surveillance in Sudan.

Sudan faces inter-sectional health risks posed by escalating violent conflict, natural hazards and epidemics. Epidemics are frequent and overlapping, particularly resurgent seasonal outbreaks of diseases such as malaria, cholera. To improve response, the Sudanese Ministry of Health manages multiple disease surveillance systems, however, these systems are fragmented, under resourced, and disconnected from epidemic response efforts. Inversely, civic and informal community-led systems have often organically led outbreak responses, despite having limited access to data and resources from formal outbreak detection and response systems. Leveraging a communal sense of moral obligation, such informal epidemic responses can play an important role in reaching affected populations. While effective, localised, and organised-they cannot currently access national surveillance data, or formal outbreak prevention and response technical and financial resources. This paper calls for urgent and coordinated recognition and support of community-led outbreak responses, to strengthen, diversify, and scale up epidemic surveillance for both national epidemic preparedness and regional health security.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.