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A worldwide watch: disease surveillance in low- and middle-income countries

Disease surveillance and reporting is critical to public health, enabling faster and better response to infectious disease outbreaks. As outlined in a previous blog, disease surveillance also plays an important role in developing vaccines for emerging infectious diseases more quickly, which, in turn, helps to limit the spread of these diseases.

Many emerging diseases are zoonotic in origin, meaning that they are transmitted by infected animals — and people who work in agriculture or live in rural settings are most likely to come into contact with animals carrying these diseases. With approximately half of their populations estimated to be rural, low- and middle-income countries (LMICs) are particularly at risk from emerging infectious diseases1. However, LMICs also face many challenges in regard to disease surveillance that high-income countries do not, and that call for unique solutions.

 

Challenges

One of the main challenges LMICs face in implementing robust disease surveillance is the lack of resources. By definition, LMICs have fewer financial resources than high-income countries, meaning that funding for surveillance is not always ideal or sustainable. However, human resources are often lacking as well, with high turnover for professionals engaged in disease surveillance. In these cases, inadequate training and uncoordinated supervision can combine with insufficient compensation and a high burden of work to demoralize personnel2.

Additionally, infrastructural concerns make disease surveillance and reporting more difficult. The internet, for example, empowers fast, powerful tools to communicate surveillance data. However, only about 35 percent of the people living in developing countries have access to the internet, introducing significant geographical gaps in the ability to use these tools for surveillance3. This is particularly detrimental in the remote and rural areas that are at notable risk for emerging infectious diseases, which may be located at great distance from other health centers.

Another problem is that passive surveillance, which is viewed as an inexpensive method to conduct surveillance on large areas, is not always suitable for rural LMIC populations. This method involves local hospitals, clinics and the like submitting reports to a health jurisdiction — but it depends on strong relationships with the surrounding community. When factors such as inaccessibility, distrust and regional conflict weaken these relationships, as may be the case for many rural LMIC populations, large portions of the population are excluded from reports4.

 

Solutions

While one of the more obvious approaches to supporting surveillance in LMICs is to provide more material resources, there are other paths that may make a positive difference as well.

One option is to support the increased training of physicians and veterinarians working in remote areas to support disease surveillance. With a strengthened understanding of zoonotic disease, including the presentation and diagnosis of known diseases, as well as the identification of potential novel zoonoses, clinicians will be better equipped to contribute to surveillance efforts. In particular, developing the skills to adapt to different disease scenarios, rather than learning purely technical skills, has been identified as an area that is particularly necessary.4 This training would help clinicians to be better prepared for a variety of situations. Additionally, larger numbers of trained staff would help to distribute workload and decrease the burden of work (and therefore stress) on any individual.

Another possibility to complement existing surveillance systems is the use of mobile phones to enable participatory surveillance, in which health officials can call or otherwise contact community members through mobile phones. This method has been used to track such emerging diseases as COVID-19 in resource-limited settings, enabled by the growing number of people in LMICs who own mobile phones.5 Such methods can help to mitigate the difficulties associated with geographic distance and the lack of internet access. However, this method does call for care to ensure that rural phone ownership is high enough in the country of interest, as otherwise data may skew towards urban areas at lower risk for contact with emerging infectious diseases.

 

A complex situation

Overcoming the barriers to improved disease surveillance in LMICs is a complex endeavor, and no single solution will definitively solve every difficulty. However, with numerous ways to support surveillance, our ability to detect and respond to emerging infectious diseases has significant potential to improve — so long as action is taken.

For more information on the role of disease surveillance and reporting in emerging infectious disease response, read the whitepaper, ‘Fortifying vaccines: Preparation and prevention against future infectious disease epidemics’.

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