Surveillance strategies for the detection of disease outbreaks in the Pacific islands: meta-analysis of published literature, 2010-2019.

OBJECTIVE: Due to their tropical location, development status and the limited capacity of health systems, Pacific island counties and territories are particularly susceptible to infectious disease outbreaks; but evidence as to the optimal way in which outbreaks are detected is scarce. In this review, we synthesise evidence from literature about how outbreaks are detected in Pacific island countries and territories and critique factors identified as inhibiting surveillance practice. METHOD: For this systematic review, we searched electronic databases Embase, Global Health, MEDLINE and MEDLINE Epub from 1 January 2010 and 31 March 2019 for reports describing infectious disease outbreaks occurring in the Pacific islands. Reports were included if they reported the method by which an outbreak was detected or the time between an outbreak's onset and its detection. We extracted information about the report type and authors, the outbreak and its method/s of detection, and pertinent issues inhibiting surveillance practice. RESULTS: Of 860 articles identified, 37 reports describing 39 outbreaks met the inclusion criteria. Most outbreaks (n = 30) were identified through formal event-based surveillance; six through syndromic surveillance; and two by ad hoc notification from the community. Barriers to early outbreak detection included population isolation; lack of resources and infrastructure to support surveillance implementation and signal investigation; and broader health system factors such as preparedness planning and availability of laboratory services. CONCLUSION: Most surveillance-related gain in the Pacific islands may be made through building formal event-based surveillance systems and streamlining reporting processes to facilitate outbreak notification. This observation is pertinent given the focus on establishing and expanding syndromic surveillance approaches for outbreak detection in the islands over the last decade.

OBJECTIF: En raison de leur situation tropicale, de leur état de développement et de la capacité limitée des systèmes de santé, les comtés et territoires des îles du Pacifique sont particulièrement sensibles aux épidémies de maladies infectieuses, mais les données quant à la manière optimale de détecter les épidémies sont rares. Dans cette étude, nous synthétisons les données de la littérature sur la manière dont les épidémies sont détectées dans les pays et territoires des îles du Pacifique et les facteurs critiques identifiés comme entravant la pratique de la surveillance. MÉTHODE: Pour cette analyse systématique, nous avons recherché dans les bases de données électroniques Embase, Global Health, MEDLINE et MEDLINE Epub du 1er janvier 2010 et du 31 mars 2019 pour des rapports décrivant les épidémies de maladies infectieuses survenant dans les îles du Pacifique. Les rapports ont été inclus s'ils indiquaient la méthode de détection d'une épidémie ou le délai entre le début d'une épidémie et sa détection. Nous avons extrait les informations sur le type de rapport et les auteurs, l'épidémie et sa ou ses méthodes de détection, ainsi que les problèmes pertinents qui entravent la pratique de la surveillance. RÉSULTATS: Sur les 860 articles identifiés, 37 rapports décrivant 39 ménages ont satisfait aux critères d'inclusion. La plupart des épidémies (n = 30) ont été identifiés suite à une surveillance formelle basée sur les événements, six suite à une surveillance syndromique et deux suite à une notification ad-hoc de la communauté. Les obstacles à la détection précoce des épidémies comprennent l'isolement de la population, le manque de ressources et d'infrastructures pour soutenir la mise en œuvre de la surveillance et l'investigation des signaux, ainsi que des facteurs plus généraux du système de santé tels que la planification de la préparation et la disponibilité des services de laboratoire. CONCLUSION: La plupart des gains liés à la surveillance dans les îles du Pacifique peuvent être réalisés par la mise en place de systèmes de surveillance formels basés sur les événements et l'aiguillage des processus de report pour faciliter la notification des épidémies. Cette observation est pertinente étant donné l'accent mis sur l'établissement et l'expansion des approches de surveillance syndromique pour la détection des épidémies dans les îles au cours de la dernière décennie.

Epidemic surveillance in a low resource setting: lessons from an evaluation of the Solomon Islands syndromic surveillance system, 2017.

BACKGROUND: Solomon Islands is one of the least developed countries in the world. Recognising that timely detection of outbreaks is needed to enable early and effective response to disease outbreaks, the Solomon Islands government introduced a simple syndromic surveillance system in 2011. We conducted the first evaluation of the system and the first exploration of a national experience within the broader multi-country Pacific Syndromic Surveillance System to determine if it is meeting its objectives and to identify opportunities for improvement. METHODS: We used a multi-method approach involving retrospective data collection and statistical analysis, modelling, qualitative research and observational methods. RESULTS: We found that the system was well accepted, highly relied upon and designed to account for contextual limitations. We found the syndromic algorithm used to identify outbreaks was moderately sensitive, detecting 11.8% (IQR: 6.3-25.0%), 21.3% (IQR: 10.3-36.8%), 27.5% (IQR: 12.8-52.3%) and 40.5% (IQR: 13.5-65.7%) of outbreaks that caused small, moderate, large and very large increases in case presentations to health facilities, respectively. The false alert rate was 10.8% (IQR: 4.8-24.5%). Rural coverage of the system was poor. Limited workforce, surveillance resourcing and other 'upstream' health system factors constrained performance. CONCLUSIONS: The system has made a significant contribution to public health security in Solomon Islands, but remains insufficiently sensitive to detect small-moderate sized outbreaks and hence should not be relied upon as a stand-alone surveillance strategy. Rather, the system should sit within a complementary suite of early warning surveillance activities including event-based, in-patient- and laboratory-based surveillance methods. Future investments need to find a balance between actions to address the technical and systems issues that constrain performance while maintaining simplicity and hence sustainability.

Towards effective outbreak detection: a qualitative study to identify factors affecting nurses' early warning surveillance practice in Solomon Islands.

BACKGROUND: Intelligence generated by a surveillance system is dependent on the quality of data that are collected. We investigated the knowledge, attitudes and practices of nurses responsible for outbreak early warning surveillance data collection in Solomon Islands to identify factors that influence their ability to perform surveillance-related tasks with rigour. METHODS: We interviewed 12 purposively selected surveillance nurses and conducted inductive analysis on resulting data. RESULTS: Interviewees were knowledgeable and willing to contribute to the surveillance system. Constraining factors included the perception that surveillance was less important than patient care and could be 'deferred' during busy periods and wide variability in the application of case definitions. Motivating factors were frequent in-clinic training, formal recognition for good performance, incentives and designation of a focal point. Nurses held mixed views about the effect of mobile technologies on surveillance practice. CONCLUSIONS: This study identified several challenges to consistent and accurate data collection and reporting. Engagement of different parts of the health system, including human resources and health facilities' management, is needed to address these challenges.

A state-wide information campaign during a pertussis epidemic in New South Wales, 2010.

Pertussis notifications increased dramatically in New South Wales in 2008, exceeding the rates in previous epidemic years. A state-wide, multi-faceted campaign was launched in March 2009 to provide information about pertussis prevention. A population-based survey was conducted using a Computer Assisted Telephone Interviewing facility to assess the effectiveness of sending letters to households with young infants. A representative sample of 1,200 adults across all 8 area health services was interviewed between July 2009 and September 2010, with responses weighted against the state population. Many respondents (39.7%) reported receiving the letter, while fewer (29.6%) reported receiving an adult pertussis booster in the last year, mostly in response to General Practitioner advice (40.4%). Letter receipt was associated with the uptake of an adult pertussis booster in the past 12 months by respondents (OR 5.8; 95%CI 4.1, 8.2) and other adults in the household (OR 5.1; 95%CI 3.5, 7.5), as well as knowledge about pertussis prevention. Health providers remain crucial for vaccination decision making; however letters may have contributed to an increased uptake of pertussis booster vaccination and knowledge. Health authorities may consider mailing households in future pertussis epidemics as a component of a wider communication strategy.

Treating and preventing influenza in aged care facilities: a cluster randomised controlled trial.

BACKGROUND: Influenza is an important cause of morbidity and mortality for frail older people. Whilst the antiviral drug oseltamivir (a neuraminidase inhibitor) is approved for treatment and prophylaxis of influenza during outbreaks, there have been no trials comparing treatment only (T) versus treatment and prophylaxis (T&P) in Aged Care Facilities (ACFs). Our objective was to compare a policy of T versus T&P for influenza outbreaks in ACFs. METHODS AND FINDINGS: We performed a cluster randomised controlled trial in 16 ACFs, that followed a policy of either "T"-oseltamivir treatment (75 mg twice a day for 5 days)-or "T&P"-treatment and prophylaxis (75 mg once a day for 10 days) for influenza outbreaks over three years, in addition to enhanced surveillance. The primary outcome measure was the attack rate of influenza. Secondary outcomes measures were deaths, hospitalisation, pneumonia and adverse events. Laboratory testing was performed to identify the viral cause of influenza-like illness (ILI) outbreaks. The study period 30 June 2006 to 23 December 2008 included three southern hemisphere winters. During that time, influenza was confirmed as the cause of nine of the 23 ILI outbreaks that occurred amongst the 16 ACFs. The policy of T&P resulted in a significant reduction in the influenza attack rate amongst residents: 93/255 (36%) in residents in T facilities versus 91/397 (23%) in T&P facilities (p=0.002). We observed a non-significant reduction in staff: 46/216 (21%) in T facilities versus 47/350 (13%) in T&P facilities (p=0.5). There was a significant reduction in mean duration of outbreaks (T=24 days, T&P=11 days, p=0.04). Deaths, hospitalisations and pneumonia were non-significantly reduced in the T&P allocated facilities. Drug adverse events were common but tolerated. CONCLUSION: Our trial lacked power but these results provide some support for a policy of "treatment and prophylaxis" with oseltamivir in controlling influenza outbreaks in ACFs. TRIAL REGISTRATION: [corrected] Australian Clinical Trials Registry ACTRN12606000278538.