Community-based Surveillance System Research Articles

A new laboratory-based surveillance system (Respiratory DataMart System) for influenza and other respiratory viruses in England: results and experience from 2009 to 2012

During the 2009 influenza A(H1N1) pandemic, a new laboratory-based virological sentinel surveillance system, the Respiratory DataMart System (RDMS), was established in a network of 14 Health Protection Agency (now Public Health England (PHE)) and National Health Service (NHS) laboratories in England. Laboratory results (both positive and negative) were systematically collected from all routinely tested clinical respiratory samples for a range of respiratory viruses including influenza, respiratory syncytial virus (RSV), rhinovirus, parainfluenza virus, adenovirus and human metapneumovirus (hMPV). The RDMS also monitored the occurrence of antiviral resistance of influenza viruses. Data from the RDMS for the 2009–2012 period showed that the 2009 pandemic influenza virus caused three waves of activity with different intensities during the pandemic and post pandemic periods. Peaks in influenza A(H1N1)pdm09 positivity (defined as number of positive samples per total number of samples tested) were seen in summer and autumn in 2009, with slightly higher peak positivity observed in the first post-pandemic season in 2010/2011. The influenza A(H1N1)pdm09 virus strain almost completely disappeared in the second postpandemic season in 2011/2012. The RDMS findings are consistent with other existing community-based virological and clinical surveillance systems. With a large sample size, this new system provides a robust supplementary mechanism, through the collection of routinely available laboratory data at minimum extra cost, to monitor influenza as well as other respiratory virus activity. A near real-time, daily reporting mechanism in the RDMS was established during the London 2012 Olympic and Paralympic Games. Furthermore, this system can be quickly adapted and used to monitor future influenza pandemics and other major outbreaks of respiratory infectious disease, including novel pathogens.

Initial findings from the implementation of a community-based sentinel surveillance system to assess the health effects of climate change in Alaska

BackgroundThis report describes the results of a study to determine whether a community-based sentinel surveillance system can be developed and implemented to assess the health effects of climate change, and to contribute to local discussions to mitigate these health effects. The purpose of this report is to describe the process and outcomes of this innovative approach to identifying priority areas for adaptation investment. This report can be used to assist local, state and federal governments in determining how to develop actions and policies to promote adaptation to climate change.ObjectiveTo evaluate the health effects of climate change in rural Alaska.DesignWe conducted an iterative and participatory process to develop metrics, an instrument and a protocol to collect sentinel surveillance data on the health effects of climate change in 3 ecologically distinct regions of the state.ResultsWe collected surveillance data from 91 study participants over the course of 12 months. These data were analyzed and categorized by frequency and association between specific health outcomes or health-related factors (such as food security) and reported exposure to environmental effects of climate change. We found significant associations between several health outcomes and health outcome mediators and reported exposures. We presented these data to study participants in community settings and moderated discussions of likely causal factors for these measured associations, and helped community residents to identify specific adaption measures to mitigate those health effects.ConclusionsWe conclude that community-based sentinel surveillance is an effective method for assessing health outcomes from exposure to environmental effects of climate change, and informing climate change health adaptation planning in Alaskan communities. We contend that it would be effective in other regions of the nation as well.

Implementation and utilisation of community-based mortality surveillance: a case study from Chad.

BackgroundProspective surveillance is a recognised approach for measuring death rates in humanitarian emergencies. However, there is limited evidence on how such surveillance should optimally be implemented and on how data are actually used by agencies. This case study investigates the implementation and utilisation of mortality surveillance data by Médecins Sans Frontières (MSF) in eastern Chad. We aimed to describe and analyse the community-based mortality surveillance system, trends in mortality data and the utilisation of these data to guide MSF’s operational response.MethodsThe case study included 5 MSF sites including 2 refugee camps and 3 camps for internally displaced persons (IDPs). Data were obtained through key informant interviews and systematic review of MSF operational reports from 2004–2008.ResultsMortality data were collected using community health workers (CHWs). Mortality generally decreased progressively. In Farchana and Breidjing refugee camps, crude death rates (CDR) decreased from 0.9 deaths per 10,000 person-days in 2004 to 0.2 in 2008 and from 0.7 to 0.1, respectively. In Gassire, Ade and Kerfi IDP camps, CDR decreased from 0.4 to 0.04, 0.3 to 0.04 and 1.0 to 0.3. Death rates among children under 5 years (U5DR) followed similar trends. CDR and U5DR crossed emergency thresholds in one site, Kerfi, where CDR rapidly rose to 2.1 and U5DR to 7.9 in July 2008 before rapidly decreasing to below emergency levels by September 2008.DiscussionMortality data were used regularly to monitor population health status and on two occasions as a tool for advocacy. Lessons learned included the need for improved population estimates and standardized reporting procedures for improved data quality and dissemination; the importance of a simple and flexible model for data collection; and greater investment in supervising CHWs.ConclusionsThis model of community based mortality surveillance can be adapted and used by humanitarian agencies working in complex settings. Humanitarian organisations should however endeavour to disseminate routinely collected mortality data and improve utilisation of data for operational planning and evaluation. Accurate population estimation continues to be a challenge, limiting the accuracy of mortality estimates.

A Sentinel Platform to Evaluate Influenza Vaccine Effectiveness and New Variant Circulation, Canada 2010–2011 Season

During the 2010-2011 winter, a large number of outbreaks due to influenza A/H3N2 at long-term care facilities, including higher-than-expected attack rates among vaccinated staff, were reported in some regions of Canada. Interim analysis from the community-based sentinel surveillance system showed circulating H3N2 variants and suboptimal vaccine effectiveness (VE), assessed here for the entire season's data set. Nasal/nasopharyngeal swabs and epidemiologic details were collected from patients presenting to sentinel sites within 7 days of onset of influenza-like illness. Cases tested positive for influenza by real-time reverse-transcription polymerase chain reaction; controls tested negative. Odds ratios for medically attended, laboratory-confirmed influenza in vaccinated vs nonvaccinated participants were used to derive adjusted VE. Viruses were characterized by hemagglutination inhibition (HI), and the hemagglutinin genes of a subset were sequenced to explore vaccine relatedness. Final 2010-2011 VE analysis included 1718 participants (half aged 20-49 years), 93 with A(H1N1)pdm09, 408 with A/H3N2, and 199 with influenza B. Among adults aged 20-49 years, adjusted VE was 65% (95% confidence interval [CI], 8%-87%) for A(H1N1)pdm09 and 66% (95% CI, 10%-87%) for influenza B. Vaccine effectiveness was substantially lower for A/H3N2, at 39% (95% CI, 0%-63%). Phylogenetic analysis identified 2 circulating H3N2 variant clades, A/HongKong/2121/2010 (87%) and A/Victoria/208/2009 (11%), bearing multiple amino acid substitutions at antigenic sites (12 and 8, respectively) compared with the H3N2 vaccine component used in Canada (A/Victoria/210/2009[NYMC X-187]). However, HI characterized all H3N2 isolates as well matched to the vaccine. Public health observations of increased facility H3N2 outbreaks were consistent with the sentinel network's detection of genetic variants and suboptimal VE but not with conventional HI characterization. We highlight the utility of a multicomponent sentinel surveillance platform that incorporates genotypic, phenotypic, and epidemiologic indicators into the assessment of influenza virus, new variant circulation, vaccine relatedness, and VE.

Epidemiological transition in a rural community of northern India: 18-year mortality surveillance using verbal autopsy

BackgroundInformation on causes of death is vital for planning of health services. However, vital events registration systems are weak in developing countries. Therefore, verbal autopsy (VA) tools were incorporated in...

Community-owned resource persons for malaria vector control: enabling factors and challenges in an operational programme in Dar es Salaam, United Republic of Tanzania.

BackgroundCommunity participation in vector control and health services in general is of great interest to public health practitioners in developing countries, but remains complex and poorly understood. The Urban Malaria Control Program (UMCP) in Dar es Salaam, United Republic of Tanzania, implements larval control of malaria vector mosquitoes. The UMCP delegates responsibility for routine mosquito control and surveillance to community-owned resource persons (CORPs), recruited from within local communities via the elected local government.MethodsA mixed method, cross-sectional survey assessed the ability of CORPs to detect mosquito breeding sites and larvae, and investigated demographic characteristics of the CORPs, their reasons for participating in the UMCP, and their work performance. Detection coverage was estimated as the proportion of wet habitats found by the investigator which had been reported by CORP. Detection sensitivity was estimated as the proportion of wet habitats found by the CORPS which the investigator found to contain Anopheles larvae that were also reported to be occupied by the CORP.ResultsThe CORPs themselves perceived their role as professional rather than voluntary, with participation being a de facto form of employment. Habitat detection coverage was lower among CORPs that were recruited through the program administrative staff, compared to CORPs recruited by local government officials or health committees (Odds Ratio = 0.660, 95% confidence interval = [0.438, 0.995], P = 0.047). Staff living within their areas of responsibility had > 70% higher detection sensitivity for both Anopheline (P = 0.016) and Culicine (P = 0.012): positive habitats compared to those living outside those same areas.Discussion and conclusionsImproved employment conditions as well as involving the local health committees in recruiting individual program staff, communication and community engagement skills are required to optimize achieving effective community participation, particularly to improve access to fenced compounds. A simpler, more direct, less extensive community-based surveillance system in the hands of a few, less burdened, better paid and maintained program personnel may improve performance and data quality.

Data on school rugby injuries help pre-empt risk factors.

A community-based rugby injury surveillance system in Scotland's schools is feasible and should be encouraged, say researchers.

Perceived usefulness of a distributed community-based syndromic surveillance system: a pilot qualitative evaluation study

BackgroundWe conducted a pilot utility evaluation and information needs assessment of the Distribute Project at the 2010 Washington State Public Health Association (WSPHA) Joint Conference. Distribute is a distributed community-based syndromic surveillance system and network for detection of influenza-like illness (ILI). Using qualitative methods, we assessed the perceived usefulness of the Distribute system and explored areas for improvement. Nine state and local public health professionals participated in a focus group (n = 6) and in semi-structured interviews (n = 3). Field notes were taken, summarized and analyzed.FindingsSeveral emergent themes that contribute to the perceived usefulness of system data and the Distribute system were identified: 1) Standardization: a common ILI syndrome definition; 2) Regional Comparability: views that support county-by-county comparisons of syndromic surveillance data; 3) Completeness: complete data for all expected data at a given time; 4) Coverage: data coverage of all jurisdictions in WA state; 5) Context: metadata incorporated into the views to provide context for graphed data; 6) Trusted Data: verification that information is valid and timely; and 7) Customization: the ability to customize views as necessary. As a result of the focus group, a new county level health jurisdiction expressed interest in contributing data to the Distribute system.ConclusionThe resulting themes from this study can be used to guide future information design efforts for the Distribute system and other syndromic surveillance systems. In addition, this study demonstrates the benefits of conducting a low cost, qualitative evaluation at a professional conference.

Confirmatory factor analysis and factorial invariance analysis of the adolescent self‐report Strengths and Difficulties Questionnaire: How important are method effects and minor factors?

OBJECTIVES. This study examined the factor structure of the self-report Strengths and Difficulties Questionnaire, paying special attention to the number of factors and to negative effects of reverse-worded items and minor factors within the subscales on model fit. Furthermore, factorial invariance across gender, age, level of education, and ethnicity was investigated. DESIGN. Data were obtained from the Youth Health Monitor Rotterdam, a community-based health surveillance system. METHODS. The sample consisted of 11,881 pupils of 11-16 years old. Next to the original five-factor model, a factor model with the number of factors based on parallel analysis and scree test was investigated. Confirmatory factor analysis for ordered-categorical measures was applied to examine the goodness-of-fit and factorial invariance of the factor models. RESULTS. After allowing reverse-worded items to cross-load on the prosocial behaviour factor and adding error correlations, a good fit to the data was found for the original five-factor model (emotional symptoms, conduct problems, hyperactivity-inattention, peer problems, prosocial behaviour) and a model with four factors (emotional symptoms and peer problems, conduct problems, hyperactivity-inattention, prosocial behaviour). Factorial invariance across gender, age, level of education, and ethnicity was found for the final five- and four-factor model, except for the prosocial factor of the four-factor model that showed partial invariance across gender. Conclusions. While support was found for both models, the final five-factor model is theoretically more plausible and gained additional support as the original scales emotional problems and peer problems showed different relations with gender, educational level, and ethnicity.

Assessing the impact of malaria interventions on morbidity through a community-based surveillance system

The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment in rural Tanzania with a set of integrated interventions targeting both users and providers. The aim of this article is to evaluate the programme's impact on the community and health facility burden of malaria and to investigate the value of community-based reporting for routine malaria control programme monitoring. This work was implemented within the Ifakara Demographic Surveillance System (DSS) between 2004 and 2008. At community level the DSS staff routinely collected data on reported history of fever and severe malaria (convulsions) based on a 2-week recall. In parallel, we collected in-patient and out-patient fever and malaria diagnoses data from the 15 health facilities in the area. Treatment-seeking surveys conducted in the study area and nationally representative data were used to validate our measure of community fever. Between 2005 and 2008, community-reported fever incidence rates in children under the age of 5 years declined by 34%, from 4.9 to 3.2 average cases per child per year, whereas convulsions, a marker of severe malaria morbidity in children, decreased by 46%, from 4263 to 2320 cases for every 100,000 children per year. The decrease in the community rates was paralleled by a decrease in the health facility fever rates, although the number of fever cases seen in health facilities did not change because of population growth. Our data showed very good internal and external consistency with independent local and national surveys. There is an evidence of a substantial decline in the community burden of malaria morbidity between 2005 and 2008 in the Kilombero and Ulanga DSS areas in Tanzania, most likely as a result of malaria control efforts. The good internal and external consistency of the data shows that history of fever in the previous 2 weeks in children under the age of 5 years can be used as a morbidity monitoring tool.

Validation of a Pediatric Primary Care Network in a US Metropolitan Region as a Community-Based Infectious Disease Surveillance System

This cross-sectional study used Geographic Information System methods to compare sociodemographic and clinical characteristics of children enrolled and not enrolled in a primary care network to determine the suitability of the network to estimate population-based disease rates. We validated the network surveillance system by comparing invasive pneumococcal disease rates between network and nonnetwork children using population-based surveillance data. Among the study population of 130300 children, network children were more likely to be female, Black, non-Hispanic, younger, and receive Medicaid. These differences varied across neighborhoods, however, adjusting for neighborhood characteristics did not significantly change observed differences. Rates of invasive pneumococcal disease were not significantly different between network and non-network children. Significant demographic and clinical differences existed between network and non-network children and varied over small areas. Observed population rates of an infectious disease did not significantly differ suggesting that the network can potentially provide valid disease estimates for the community population.

Intervention communautaire pour réduire au Mali la mortalité néonatale due à l'asphyxie

Résumé Environ un million de nouveau-nés meurent chaque année d’asphyxie dans les pays en développement. Les objectifs de cette étude étaient de former à la prise en charge de l’asphyxie néonatale au niveau communautaire et d’établir un système de surveillance des évènements vitaux, en milieu rural de Oueléssébougou, Mali. Des accoucheuses traditionnelles (AT), des femmes leaders d’associations villageoises et des agents de santé villageois (relais) ont été formés pour mener des activités de communication pour le changement de comportement dans le cadre de la prise en charge de l’asphyxie. L’étude a permis d’améliorer le taux d’accouchement dans les structures sanitaires (80 à 93 %), la reconnaissance de l’asphyxie du nouveau-né (11 à 12 % des enfants ont été réanimés). La?formation et le suivi des acteurs communautaires permettent d’améliorer la qualité des accouchements et réduire la mortalité néonatale.

Achieving high coverage of larval-stage mosquito surveillance: challenges for a community-based mosquito control programme in urban Dar es Salaam, Tanzania.

BackgroundPreventing malaria by controlling mosquitoes in their larval stages requires regular sensitive monitoring of vector populations and intervention coverage. The study assessed the effectiveness of operational, community-based larval habitat surveillance systems within the Urban Malaria Control Programme (UMCP) in urban Dar es Salaam, Tanzania.MethodsCross-sectional surveys were carried out to assess the ability of community-owned resource persons (CORPs) to detect mosquito breeding sites and larvae in areas with and without larviciding. Potential environmental and programmatic determinants of habitat detection coverage and detection sensitivity of mosquito larvae were recorded during guided walks with 64 different CORPs to assess the accuracy of data each had collected the previous day.ResultsCORPs reported the presence of 66.2% of all aquatic habitats (1,963/2,965), but only detected Anopheles larvae in 12.6% (29/230) of habitats that contained them. Detection sensitivity was particularly low for late-stage Anopheles (2.7%, 3/111), the most direct programmatic indicator of malaria vector productivity. Whether a CORP found a wet habitat or not was associated with his/her unfamiliarity with the area (Odds Ratio (OR) [95% confidence interval (CI)] = 0.16 [0.130, 0.203], P < 0.001), the habitat type (P < 0.001) or a fence around the compound (OR [95%CI] = 0.50 [0.386, 0.646], P < 0.001). The majority of mosquito larvae (Anophelines 57.8% (133/230) and Culicines 55.9% (461/825) were not reported because their habitats were not found. The only factor affecting detection of Anopheline larvae in habitats that were reported by CORPs was larviciding, which reduced sensitivity (OR [95%CI] = 0.37 [0.142, 0.965], P = 0.042).ConclusionsAccessibility of habitats in urban settings presents a major challenge because the majority of compounds are fenced for security reasons. Furthermore, CORPs under-reported larvae especially where larvicides were applied. This UMCP system for larval surveillance in cities must be urgently revised to improve access to enclosed compounds and the sensitivity with which habitats are searched for larvae.

EVALUATING COMPLETENESS OF MATERNAL MORTALITY REPORTING IN A RURAL HEALTH AND SOCIAL AFFAIRS UNIT IN VELLORE, INDIA, 2004

Health systems in developing countries infrequently implement and evaluate maternal death surveillance. This study identified under-reported and misclassified maternal deaths among women of reproductive age between 1999 and 2004 in a rural service unit in Vellore, India. In-depth interviews, semi-structured interviews and structured questionnaires were used to identify maternal deaths known to health care providers and community leaders who regularly come in contact with pregnant women. Eighteen under-reported and misclassified cases--or 50% of maternal deaths--were reported. These included 29% of abortion-related and 7% of domestic violence-related deaths. Based on this study's fieldwork, the existing death surveillance system detected 100% of the maternal deaths reported by hospital staff; however, it missed most maternal deaths reported by community workers. The latter are more likely than deaths reported by hospital workers to result from abortion and family violence. The existing surveillance system should be augmented with a community-based death surveillance system. This comprehensive approach identified twice as many maternal deaths than previously recorded and could be applied in other settings. Appropriate public health interventions should be initiated to prevent maternal deaths in this community.

When is deliberate killing of young children justified? Indigenous interpretations of infanticide in Bolivia

In the Andes, as elsewhere, infanticide is a difficult challenge that remains largely undocumented and misunderstood. From January to March 2004 we used community-based vital event surveillance systems, discussions with health staff, ethnographic interviews, and focus group discussions among Aymara men and women from two geographically distinct sites in the Andes of Bolivia to provide insights into the practice of infanticide. We noted elevated mortality at both sites. In one location, suspected causes of infanticide were especially high for girls. We also observed that community members maintain beliefs that justify infanticide under certain circumstances. Among the Aymara, justification for infanticide was both biological (deformities and twinship) and social (illegitimate birth, family size and poverty). Communities generally did not condemn killing when reasons for doing so were biological, but the taking of life for social reasons was rarely justified. In this cultural context, strategies to address the challenge of infanticide should include education of community members about alternatives to infanticide. At a program level, planners and implementers should target ethnic groups with high levels of infanticide and train health care workers to detect and address multiple warning signs for infanticide (for example, domestic violence and child maltreatment) as well as proxies for infant neglect and abuse such as mother/infant separation and bottle use.

Epidemiology of Maternal Mortality in Malawi.

In Malawi the number of maternal deaths has been estimated using hospital-based surveys and populationbased surveys. The results of these studies sorted by setting and year of the study are presented in table 1. In addition large community-based surveillance systems are currently being implemented by the Karonga Prevention Study of the London School of Hygiene and Tropical Medicine in the South of Karonga District and by the Centre for Reproductive Health of the College of Medicine in the Lungwena area in Mangochi District. Estimates from hospital-based studies concerning the period 1977 to 1990 range from 32 to 945 maternal deaths per 100000 live births. More recent estimates have not been found. The MMR estimated from community surveys in the eighties to early nineties varied from 398 to 620. For the late nineties only the MDHS estimate of the MMR is available which is 1120 maternal deaths per 100000 live births. (excerpt)

Persisting high hospital and community childhood mortality in an urban setting in Guinea‐Bissau

To describe paediatric hospitalization in a West African capital in relation to overall childhood mortality in the community and to evaluate the potential impact of improved management at the hospital. Hospital data on child admissions in a 6-year period were linked to information in a community-based longitudinal surveillance system. Paediatric hospitalization rates, risk factors for hospitalizations, community mortality, in-hospital mortality and the proportion of deaths occurring at hospital were examined. Almost 15% of infants and 45% of children less than 5 years of age had been hospitalized, and 24% of all deaths in the community occurred in-hospital. Community infant and under-three mortality rates were 110 and 207 per 1,000 person-years, respectively. In-hospital mortality remained persistently high from 1991 to 1996 and the overall in-hospital mortality was 12%. It was found that wet season, lack of maternal schooling and living in a specific district were significant risk factors for both community and in-hospital death, whereas higher hospitalization rates were associated with better-off families. In populations with high hospitalization rates, even minor improvements in acute case management of sick children attending the hospital would be expected to result in substantial reduction in overall childhood mortality. Persistently high acute in-hospital mortality reflects the need of immediate and appropriate care at the hospital. Treatment should be free of charge, in order to minimize the impact of social inequality.

Community‐based surveillance: a pilot study from rural Cambodia

This study seeks to assess the performance of a community-based surveillance system (CBSS), developed and implemented in seven rural communes in Cambodia from 2000 to 2002 to provide timely and representative information on major health problems and life events, and so permit rapid and effective control of outbreaks and communicable diseases in general. Lay people were trained as Village Health Volunteers (VHVs) to report suspected outbreaks, important infectious diseases, and vital events occurring in their communities to local health staff who analysed the data and gave feedback to the volunteers during their monthly meetings. Over 2 years of its implementation, the system was able to detect outbreaks early, regularly monitor communicable disease trends, and to provide continuously updated information on pregnancies, births and deaths in the rural areas. In addition, the system triggered effective responses from both health staff and VHVs for disease control and prevention and in outbreaks. A CBSS can successfully fill the gaps of the current health facility-based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Its replication or adaptation for use in other rural areas in Cambodia and in other developing countries is likely to be beneficial and cost-effective.

Building capacity for risk factor surveillance in developing countries: a new approach

The need to create surveillance systems that go beyond data release and generate useful, relevant and accessible information has been widely recognized. To reach this goal the design and implementation of surveillance systems should consider not only technical issues but aspects that guarantee their sustainability and utility and more important, the utilization of surveillance data for resource allocation and planning of health programs and interventions. Until now key issues have been neglected, such as political will, community involvement, decision-making processes and accountability in surveillance outcomes. For many years we have faced the same problems, all within an epidemiological mosaic where infectious and communicable diseases coexist, with limited capacity to conduct surveillance, low priority given by decision-makers, lack of resources, scarce utilization of information, competing priority between chronic, infectious diseases and risk factors surveillance. Technical, management and political approaches involving new partnerships, new ways to involve different stakeholders in the process, new methods and tools, ways to overcome resource restrictions and improve surveillance effectiveness, have to be achieved. An alternative approach has been suggested to meet the above problems and to make surveillance socially responsible; relevant and effective, not only for reporting, but for its contribution to produce the needed health changes and sustain these outcomes. The vision, strategies, methods, tools and results of a community-based surveillance system are presented. Three aspects are addressed, the context in which the surveillance is applied; the theory supporting behavioural risk factor surveillance; the perspectives, goals, solutions and lessons learned from previous experience.

The Evolution of a Community-based Child Injury Surveillance Project

abstractThe development of the community-based health information systems is a constant challenge for any national health system wishing to implement information technology in healthcare. The challenge is further heightened by the high failure rate of 70 to 80 per cent in information systems projects. The development of a community-based child injury surveillance system in a local government unit in Metro Manila offers lessons that spurred the project proponents to alter the course of the systems development to a more favourable but challenging outcome, that of creating a system that responds to actual end-user needs and organizational requirements and creates value at the level of data collection. Two key communications technologies are used: Internet technologies (specifically the Web) and GSM short messaging system.