Availability of indicators of migration in the surveillance of HIV, tuberculosis and hepatitis B in the European Union – a short note

This review examines Nigeria's need for enhanced infectious disease response and surveillance systems, comparing current models and effective deployments from other nations. The review adopted the critical literature analysis method to synthesise findings from peer-reviewed journal articles, official reports, and case studies. The analysis compared Nigeria's infectious disease surveillance, response, and intervention practices with global best practices to identify gaps and propose actionable recommendations. Findings revealed serious weaknesses in Nigeria's infectious diseases surveillance system. For instance, COVID-19 exposed serious flaws in the nation’s contact tracing and testing capacity, with about 1.78 million samples tested by mid-2021, compared with 3.2 million in South Africa. Whereas, malaria causes 60% of outpatient visits and more than 194,000 mortalities annually. About 41 mortalities were linked to cholera epidemics within the second quarter of 2024, resulting from inadequate water and sanitation facilities. Findings revealed underreporting of infectious diseases in Nigeria, including Tuberculosis (TB) where 15.5% of bacteriologically confirmed cases in Lagos in 2022 went unreported. During the early outbreak of COVID-19, only 10–50% of symptomatic cases were reported. Findings also showed the financial burden posed by infectious diseases, including malaria which costs Nigeria about $1.1 billion annually. To improve disease surveillance and response in Nigeria, the review recommended the implementation of digital health technologies including mHealth and GIS mapping. While also enhancing healthcare worker training, instituting integrated disease surveillance systems, and fortifying health policy frameworks.

Background: Infectious diseases cause a considerable burden to population health worldwide. Different types of surveillance systems have been implemented to assess changes in disease frequency, to identify outbreaks, and to detect newly emerging diseases aiming at early detection of epidemics, disease control and prevention. Passive surveillance systems are mostly used, measuring the ‘incidence of notified cases’ rather than the incidence (frequency) of disease at population level. Foodborne pathogens, for example, do not always cause disease in infected individuals. Sick individuals – mostly presenting with acute gastroenteritis (AG) – do not always seek healthcare. Of those approaching a physician, aetiology of disease is investigated only in a fraction of patients. Finally, not all cases with a positive laboratory finding for a notifiable pathogen might be reported to the surveillance system. This “loss” of cases along the so-called burden of illness pyramid – from infection to actual notification in the surveillance system –, or the factor of underestimation, depends on the pathogen and the local health (care) system. Two surveillance systems are implemented in Switzerland which are important for infectious disease surveillance and early detection: the National Notification System for Infectious Diseases (NNSID) and the Swiss Sentinel Surveillance Network (Sentinella). The NNSID is based on the Epidemics Act and is the only mandatory surveillance system in Switzerland covering the entire nation and involving all physicians and diagnostic laboratories. The Epidemics Act defines which observations have to be reported to the NNSID and stipulates the time frame for reporting. Sentinella is a network where information from a subset of voluntarily participating physicians is collected to study diseases and health issues at the primary care level. It was estimated that 31 foodborne hazards caused 33 million Disability Adjusted Life Years (DALYs) and 600 million cases of illness worldwide in 2010. In European countries, the incidence of AG was estimated at 0.3–1.5 disease episodes per person-year. Campylobacter spp. is the most frequent, notifiable, bacterial foodborne disease, both in the European Union (EU) and in Switzerland and showed increasing trends in the past decade. In contrast, Salmonella spp. notifications were decreasing in the EU and in Switzerland while enterohaemorrhagic Escherichia coli (EHEC) notifications were increasing in Switzerland but remained stable in the EU. In Switzerland, information on foodborne diseases is mostly restricted to data obtained through the NNSID. Many factors contribute to underestimation and hence, it is unclear how well notification rates reflect disease incidence. Objectives: This work aimed at contributing to a better understanding of the burden of illness pyramid for foodborne infections in Switzerland and, thus, contributing to improve infectious disease surveillance and control. It sought to investigate the frequency of cases of foodborne disease or AG at different…

To the Editor: Medical examiners and coroners (ME/C) investigate ≈20% of all deaths in the United States (1); these include persons who die outside the health care system or die precipitously without a confirmed diagnosis. Surveillance through ME/C offices for unexplained deaths that might have infectious causes can serve as a sentinel system to identify new agents, identify notifiable diseases missed by traditional surveillance systems, recognize unique signs and symptoms of known pathogens, and detect bioterrorism (1). This surveillance model, called Med-X, is based on standards for autopsy performance, diagnostic testing, and public health reporting and is currently being performed locally in a small number of offices. To assess more widely the capacity of ME/C offices to conduct infectious disease surveillance, the National Association of Medical Examiners distributed an Internet-based questionnaire to 155 ME/C offices in the United States that serve populations >300,000; the questionnaires were completed during August–September 2009. Survey questions addressed interest in and physical, personnel, and logistical capacities for conducting surveillance for deaths that could have resulted from infectious diseases. Because many infections can be transmitted during autopsy, specific biosafety features for the autopsy suite were also assessed. The ME/C offices that responded (68/155) are responsible for 59% of the population served by the target ME/C offices and, on average, perform autopsies on 33% (range 12%–80%) of their cases. Most of the responding offices were the principal office for the area, which was primarily at the county or parish level. Of the responding offices, 97% indicated an interest in a medical examiner–based surveillance system for infectious diseases; 13% currently identify and report cases through the Med-X system. Almost half of the respondents noted some Biosafety Level 3 features in their facilities, including negative pressure ventilation, double-door entry into autopsy suites, or appropriate air exchange and ventilation systems. With respect to current capabilities and practices of surveillance of infectious diseases, most respondents had optimal databases that contained complete and searchable data that included circumstances of death narrative, autopsy findings, and laboratory results. Most offices also had established practices of identifying infectious diseases and of reporting to local or state health departments notifiable and nonnotifiable diseases. The most often cited barriers to participation in ME/C infectious disease surveillance were funding and resources (85%), lack of supplies (76%), insufficient laboratory testing capability (69%), and personnel requirements (63%). These factors all relate primarily to the subsequent autopsies resulting from the surveillance. With respect to current autopsy practices, survey results suggest that inadequate usage of personal protective equipment (6%), lack of autopsy suites with negative pressure (21%), and inadequate required vaccinations (e.g., hepatitis B) for pathologists (40%) are areas where improvement is needed. During the past few decades, several diseases of public health importance, including new or emerging infectious diseases, have been recognized and identified through the collaborative efforts of public health partners and medical examiners, performance of autopsies, and subsequent postmortem diagnostic testing (2–4). The findings from this survey suggest that interest and potential exist for the establishment of an enhanced national ME/C-based surveillance system for novel or emerging infectious diseases and bioterrorism. A surveillance protocol is already available for distribution (5). Although survey respondents showed high interest in such a system, this result may be an overestimation because of the offices targeted and the low overall response rate. Addressing existing barriers, including funding and infrastructure deficiencies, may increase participation in such a national surveillance system. Development of a national surveillance system of this type would require fulfilling recently identified steps needed to strengthen the competency of national death investigation systems (6), establishment of uniform statewide and interstate standards of operation such as those outlined in the National Association of Medical Examiners accreditation checklist (7), consolidation of smaller offices, regionalization of services, and standardization of staff training.

Lessons from the COVID-19 Pandemic—Unique Opportunities for Unifying, Revamping and Reshaping Epidemic Preparedness of Europe’s Public Health Systems

BackgroundRisk assessment and early warning (RAEW) are essential components of any infectious disease surveillance system. In light of the International Health Regulations (IHR)(2005), this study compares the organisation of RAEW in China and the Netherlands. The respective approaches towards surveillance of arboviral disease and unexplained pneumonia were analysed to gain a better understanding of the RAEW mode of operation. This study may be used to explore options for further strengthening of global collaboration and timely detection and surveillance of infectious disease outbreaks.MethodsA qualitative study design was used, combining data retrieved from the literature and from semi-structured interviews with Chinese (5 national-level and 6 provincial-level) and Dutch (5 national-level) experts.ResultsThe results show that some differences exist such as in the use of automated electronic components of the early warning system in China (‘CIDARS’), compared to a more limited automated component in the Netherlands (‘barometer’). Moreover, RAEW units in the Netherlands focus exclusively on infectious diseases, while China has a broader ‘all hazard’ approach (including for example chemical incidents). In the Netherlands, veterinary specialists take part at the RAEW meetings, to enable a structured exchange/assessment of zoonotic signals.ConclusionDespite these differences, the main conclusion is that for the two infections studied, the early warning system in China and the Netherlands are remarkably similar considering their large differences in infectious disease history, population size and geographical setting. Our main recommendations are continued emphasis on international corporation that requires insight into national infectious disease surveillance systems, the usage of a One Health approach in infectious disease surveillance, and further exploration/strengthening of a combined syndromic and laboratory surveillance system.

The EU Response to COVID-19: From Reactive Policies to Strategic Decision-Making.

ABSTRACTNigeria has experienced outbreaks of multiple infectious diseases, a major public health concern, in the last 10 years, including the Ebola virus in 2014, monkeypox in 2017, COVID‐19 in 2020, Lassa fever in 2022, measles in 2023, diphtheria in 2023, and the cholera outbreak in 2024. This emphasizes the importance of implementing a robust infectious disease surveillance system for illness response, prevention, and control. This review examines the current status of infectious disease surveillance system in Nigeria and its usefulness in preparing for future outbreaks. A network of laboratories, community health workers, health facilities, and epidemiology units was established during the COVID‐19 epidemic by the Nigeria Centre for Disease Control (NCDC), which is essential to disease surveillance. One of the surveillance system's tiers, state epidemiology units, was in charge of overseeing the gathering and reporting of regional data. Community health workers also carried out contact tracing and public health education as a grassroots method of disease surveillance. The NCDC adopted the Surveillance Outbreak Response Management and Analysis Systems as a primary digital surveillance platform for implementing the Integrated Disease Surveillance and Response system, which is specifically tailored for the surveillance of priority diseases of public health importance in Nigeria. This was done to effectively improve the surveillance capacity and data management. It is critical to enhance the current surveillance system's ability to monitor, anticipate, and quickly respond to disease outbreaks. The COVID‐19 outbreak highlighted the need for surveillance system improvement, particularly gaps that need to be closed to monitor future outbreaks or resurgences. To fortify the surveillance system for infectious diseases, it is imperative to continue utilizing the knowledge gained from prior outbreaks, enhance data collection, enhance national and subnational surveillance systems, and enhance laboratory surveillance systems with precise data gathering and dissemination.

An effective infectious disease surveillance and early warning system is a crucial component of public health safety and is essential for preventing and controlling outbreaks of infectious diseases. Enhancing surveillance and early warning capabilities is an urgent priority for advancing high-quality disease prevention and control efforts. Combining the research findings and practical experiences of experts in epidemiology, clinical medicine, disease prevention and control, data science, and computer science, and following multiple rounds of expert discussions, we have developed a consensus on the key technologies for a multi-point trigger intelligent surveillance and early warning system for infectious diseases. This consensus primarily covers the related concepts and definitions of the multi-point trigger intelligent surveillance and early warning system for infectious diseases, the key technical framework, sources, acquisition, and governance of multi-channel warning data, classification of early warning methods, multi-point trigger intelligent surveillance and early warning paths, multi-point trigger warning and comprehensive assessment, response to warning signals, and evaluation of early warning effectiveness. It aims to provide technical references for the construction and application of a multi-point trigger intelligent surveillance and early warning system for infectious diseases.

BackgroundNovel surveillance approaches using digital technologies, including the Internet of Things (IoT), have evolved, enhancing traditional infectious disease surveillance systems by enabling real-time detection of outbreaks and reaching a wider population. However, disparate, heterogenous infectious disease surveillance systems often operate in silos due to a lack of interoperability. As a life-changing clinical use case, the COVID-19 pandemic has manifested that a lack of interoperability can severely inhibit public health responses to emerging infectious diseases. Interoperability is thus critical for building a robust ecosystem of infectious disease surveillance and enhancing preparedness for future outbreaks. The primary enabler for semantic interoperability is ontology.ObjectiveThis study aims to design the IoT-based management of infectious disease ontology (IoT-MIDO) to enhance data sharing and integration of data collected from IoT-driven patient health monitoring, clinical management of individual patients, and disparate heterogeneous infectious disease surveillance.MethodsThe ontology modeling approach was chosen for its semantic richness in knowledge representation, flexibility, ease of extensibility, and capability for knowledge inference and reasoning. The IoT-MIDO was developed using the basic formal ontology (BFO) as the top-level ontology. We reused the classes from existing BFO-based ontologies as much as possible to maximize the interoperability with other BFO-based ontologies and databases that rely on them. We formulated the competency questions as requirements for the ontology to achieve the intended goals.ResultsWe designed an ontology to integrate data from heterogeneous sources, including IoT-driven patient monitoring, clinical management of individual patients, and infectious disease surveillance systems. This integration aims to facilitate the collaboration between clinical care and public health domains. We also demonstrate five use cases using the simplified ontological models to show the potential applications of IoT-MIDO: (1) IoT-driven patient monitoring, risk assessment, early warning, and risk management; (2) clinical management of patients with infectious diseases; (3) epidemic risk analysis for timely response at the public health level; (4) infectious disease surveillance; and (5) transforming patient information into surveillance information.ConclusionsThe development of the IoT-MIDO was driven by competency questions. Being able to answer all the formulated competency questions, we successfully demonstrated that our ontology has the potential to facilitate data sharing and integration for orchestrating IoT-driven patient health monitoring in the context of an infectious disease epidemic, clinical patient management, infectious disease surveillance, and epidemic risk analysis. The novelty and uniqueness of the ontology lie in building a bridge to link IoT-based individual patient monitoring and early warning based on patient risk assessment to infectious disease epidemic surveillance at the public health level. The ontology can also serve as a starting point to enable potential decision support systems, providing actionable insights to support public health organizations and practitioners in making informed decisions in a timely manner.

Chapter 8 - Infectious Disease Surveillance and Early Warning System During Beijing Olympic Games

According to the challenges of emerging infectious diseases (EID) and bioterrorist attack in the 21st Century, the traditional infectious disease surveillance systems have lacked active surveillance and failed to detect the 2001 anthrax attacks and the 2003 cross-country spread of severe acute respiratory syndrome (SARS) early. In order to establish scientific evidence-based active infectious disease surveillance system, we initiated a hospital emergency department (ED)-based timely and automatic syndromic surveillance system (ED-SSS) in Taiwan for the basis of further epidemiological investigation. Through the introduction of the real-time outbreak and disease reporting system (RODS) from the University of Pittsburg to Taiwan, we established both a nation-wide ED-SSS involving 189 hospitals and set up more integrative procedures of local ED-SSS for daily operation, signal investigation, checking data quality and specimens taken at one regional hospital with 5 branches in metropolitan Taipei. In this study, we built up the daily operation procedures to perform further implementation and signal investigation and conducted epidemiological syndrome data analysis, using two data set of ICD-9 codes of ED visits: (1) 2,692,325 visits of nation-wide ED-SSS in Taiwan, April 1, 2004 - March 31, 2005. (2) 130,313 visits in one regional Taipei hospital, October 1, 2005- April 30, 2006. Daily patterns and trends of nation-wide ED-SSS ICD-9 codes involving 11 syndrome groups were analyzed, according to the international research experiences and recommendations of infectious disease experts in Taiwan. We found increasing trends in gastro-intestinal (GI) syndromes during winter season, and appearing peaks of respiratory or influenza-like illness (ILI) in summer periods, plus two waves of enterovirus (EV)-like infections under 6 years of age. In addition, striking increase of ED-visits were shown in weekends (1.3-fold p<0.001), and holidays, especially 2.0-fold higher during Chinese Lunar New Year (p<0.001). Most ED visits were children aged <10 y/o (18.6%) and 20-39 year-old young adults (17.4%). Male vs. female ED visits were 1.12:1. Starting from July of 2004, case numbers of fever, respiratory and ILI syndromes gradually increase, indicating possible presence of respiratory infections in Taiwan that had been seldom reported and worthwhile future investigating. Therefore, we examined the sensitivity, specificity and positive-predictive values of different ICD-9 code syndrome groupings of ILI cases from the 1,281 cases through medical charts review at C-hospital in Taipei, June 24, 2004 – July 8, 2004. The modified version of ILI syndrome that deleted asthma, fever and dizziness had 75.5% sensitivity and 84.4% specificity. We then applied it to detect ILI cases in Taipei ED-SSS. Increased numbers and earlier detected EVI syndrome cases of nation-wide ED-SSS were found in central Taiwan, but there was no significant difference in patterns by different age and gender groups. Compared with sentinel physicians’ hand-foot-mouth disease surveillance, the ED-SSS was 2 weeks earlier in detecting the increased EVI syndrome cases in Taiwan. Additionally, the Taipei X-Hospital ED-SSS also showed similar pattern. Among the patterns of other syndrome groups, GI syndrome cases in both nation-wide and Taipei ED-SSS increased from Nov. of 2004. On the other hand, Taipei X-Hospital ED-SSS with different branches showed regional differences. Moreover, 30-39 year-old male adults showed one week earlier in the increasing of ILI syndrome cases implying possible important transmission role in this age group in a metropolitan city. With the limit historical ED-SSS data, both historical control limits (HCL) using past four-week background data and cumulative sum (CUSUM) process control methods were used for our aberration detection and their required conditions in ED-SSS. The weekday and weekend stratified HCL method showed 67% sensitivity to detect the Taiwan-CDC identified outbreaks and the modified CUSUM method was too sensitive to demonstrate signals on weekends and holidays and needed to be improved due to its higher sensitivity for the changes of continuous baseline. Undoubtedly, both methods are applicable to public health use for immediate prevention and control of infectious diseases but they need further researches to reduce false signals. Evaluation of surveillance systems found that ED-SSS, providing more information for further epidemiological investigation, had the best timeliness and better flexibility to integrate with other database for multi-disciplinary research than other infectious disease surveillance systems existed. It can serve two-way frequent communications between public health agencies and medical departments. With the large baseline data of community health, it can also apply to research on other domains in public health. Future efforts are needed for continuous investment of medical informatics, to recruit more high quality infection control public health personnel, and to improve different statistical prediction models for maximizing effectiveness for early EID detection.

the Italian National HIV Surveillance, instituted by the Ministerial Decree of March 31st, 2008, is based on 21 regional surveillance systems and adopts an essential data collection form with a definite data flow. The unification of HIV and AIDS surveillance systems and the implementation of an identical data collection form are priorities of the Italian National HIV/AIDS Action Plan 2017 (PNAIDS). to describe the 21 regional HIV surveillance systems and to verify the feasibility of their unification. in March 2017, a questionnaire containing 13 questions was sent to all the regional representatives of the 21 surveillance systems. The main questions were about timeliness, data flow, and quality of the system. The quality was measured through a subjective evaluation expressed by the regional referent through scores from 1 (minimum) to 10 (maximum) regarding four indicators (regional coverage, timeliness, correctness, and completeness of the data). more than half of the regional systems use a computerized data collection method. Some of these regions have not completely adapted to the data collection form contained in the Decree and other regions declare a undernotification of the system. The majority of the regions record a slight notification delay by the reporting centres. Some regions report gaps in the completeness of the data received by the reporting centres. the main strengths of the HIV surveillance system are computerization of the systems and slightly reporting delay. Regarding the quality of the regional systems and its data, the study reports a good self-evaluation. This study also showed useful indications to improve the national HIV surveillance system, such as the unification of HIV surveillance with the AIDS surveillance and the implementation of a unique national system, as suggested by guidelines of the PNAIDS 2017.

Strengthening infectious disease surveillance in Europe

Solid and sensitive infectious disease surveillance systems need to be developed and implemented to prevent and control epidemics. Although statutory national infectious disease surveillance systems have been developed in many countries, some challenges remain, such as their limited timeliness, representativeness, and sensitivity, as well as the fact that they cannot capture all local outbreaks that occur in small communities. To overcome these limitations, local community-based infectious disease surveillance systems that meet local needs and can operate with constrained resources need to be developed, especially in remote and rural low-resource areas. This study aimed to develop, implement, and evaluate a voluntary and unique local community-based ophthalmology sentinel surveillance system in Isa city (OSSS-Isa), a remote rural area in Japan. For the development of OSSS-Isa, one hospital in Isa city assumed a leading role and developed a network with all medical institutions - 20 hospitals and clinics in the local community, including two ophthalmology clinics - as sentinel reporting sites. Surveillance was conducted on a weekly basis from Monday to Sunday. The collection, aggregation, and reporting of the surveillance data were implemented promptly on the same day, Monday, using a paper-based form and fax. For the evaluation of OSSS-Isa, the study followed the updated guidelines for evaluating public health surveillance systems proposed by the Centers for Disease Control and Prevention to select the evaluation criteria and develop a questionnaire. The questionnaires were then distributed to 20 hospitals and clinics, with the responses evaluated on a five-point Likert scale. For the implementation of OSSS-Isa, the system issued alerts twice to the networked hospitals and clinics when signs of an increase in the prevalence of a target infectious eye disease appeared in Isa city. After the alerts, the number of cases decreased in the community. Regarding the evaluation survey, physicians from 18 hospitals and clinics responded to the questionnaire (response rate 90%). In contrast to flexibility, more than 75% of the respondents gave high ratings to simplicity, data quality, acceptability, timeliness, and stability in evaluating OSSS-Isa, with the mean score for these evaluation criteria higher than 3.67. The present results indicate that OSSS-Isa has high simplicity, data quality, acceptability, timeliness, and stability, which is highly embedded with the local healthcare providers in Isa city. OSSS-Isa contributed to the early and accurate detection of signs of infectious eye disease outbreaks emerging in a small remote rural local community. The success factors seem to include its simple well-designed implementation methods, good external factors, and active human factors suited to the characteristics of the small remote rural community. The OSSS-Isa initiative appears to be a meaningful practical example of successful health advocacy by healthcare providers by developing a system at the local social level while going beyond the boundaries of routine medical practice. If voluntary small-scale surveillance systems can complement statutory large-scale ones and work together locally, nationally, and internationally, it might be possible to detect small, unusual happenings that occur in the community, such as emerging infectious diseases, and thereby help avert global outbreaks.

Despite a significant amount of progress in the past decade, global infectious disease surveillance still often falters, as in the case of the emerging novel coronavirus that has killed at least 17 people in Saudi Arabia. This article argues that we must continuously re-evaluate global infectious disease surveillance systems. It takes stock of problems in various countries' infectious disease surveillance systems and offers recommendations for how to improve surveillance and ensure more rapid reporting. Chief among the recommendations are strategies for reducing fragmentation in global surveillance systems and methods for making these systems less disease-specific. Suggestions are also offered for ways to improve infectious disease surveillance strategies in resource-limited settings.