Stopping infectious disease outbreaks through international health data reporting collaboration
In low- and middle-income countries, patients with frightening fever symptoms may never find out what caused them to get sick, even if they receive care from a doctor who is able to manage their symptoms. By one estimate, up to 40% of fevers in Africa are never diagnosed or attributed to a specific illness. By failing to properly diagnose these “fevers of unknown origin,” we not only fail to initiate appropriate treatment regimens, but also miss opportunities to contain outbreaks of dangerous infectious diseases that could be spreading within the community and then beyond.
This was not the case recently in Equatorial Guinea, where laboratories in neighboring Cameroon were able to quickly confirm that patients were suffering from Marburg disease, a highly contagious illness from a virus spread by bats that causes death in up to 88% of patients who get sick. Laboratory confirmation was a critical aspect of confirming the outbreak, because the disease caused by the Marburg virus is difficult for doctors to distinguish from other hemorrhagic fevers like Ebola.
Even so, “while the [Ministry of Health in Equatorial Guinea] has done a great job tracking cases, I think we would be foolish to assume that no cases have gone undetected,” said Nancy Sullivan, director of Boston University’s National Emerging Infectious Diseases Laboratories, at an emergency meeting convened by the World Health Organization.
Community health workers as the first line of defense
In Mali, when community health worker Djenebou Kola Cisse noticed a yellow tint in a young mother’s eyes, she suspected the woman had yellow fever, a dangerous disease that can be spread quickly by mosquitos. Cisse is one of 72 community health workers who were trained in Mali’s Kadiolo health district to recognize signs of yellow fever and other deadly infectious diseases by USAID’s Infectious Disease Detection and Surveillance (IDDS) project (ICF leads a consortium of partners to implement IDDS). The project works to improve disease detection and surveillance systems in more than 20 countries across Africa and Asia, including by implementing community-based surveillance, an approach that depends on frontline workers like Cisse who are also community members.
“With the training received on community-based surveillance and the communication tools, I can conduct sensitization sessions in my community on diseases and events under surveillance so I can detect and report suspected cases to my supervisors,” explains Yacouba Kone, another community health worker in the town of Niamala in southern Mali who was trained by IDDS. Kone used his new skills to successfully detect a case of acute flaccid paralysis, a rare but serious disease that affects the nervous system and causes muscle weakness.
Community health workers like Cisse and Kone are well positioned to receive information through informal channels, rapidly refer potential cases to health centers for diagnosis and treatment, and report findings to health officials for follow-up, typically by SMS message alerts. During a one-year period, Mali’s newly trained workers issued 761 alerts of potential public health events to district officials. IDDS has also expanded community-based surveillance in Burkina Faso, Guinea, Senegal, and Vietnam.
Transporting dangerous materials
Whether a disease case is detected by a community health worker or in a more traditional setting by a health care provider, clinicians often need laboratory confirmation of their diagnoses. To receive an accurate test result, first they must transport the patient’s specimen to a laboratory with the relevant testing capabilities, often located far away from a potential outbreak. “Effective referral systems are urgently needed to ensure that specimens reach the laboratory safely and within the timeframes where they remain viable for testing,” said Ebi Bile, IDDS Guinea team lead. IDDS has worked to improve specimen transport systems in 12 countries across Africa and Asia.
In Mali, Cisse referred the above-mentioned young woman with yellow-tinted eyes to a local health center, where a blood specimen was collected and transported to the National Institute of Public Health in Bamako, some 300 miles away, or an 8-hour journey by road. After that, the specimen traveled by plane to the Pasteur Institute of Dakar in Senegal—another 870 miles away—which was able to confirm the diagnosis. In some cases, specimens must be transported by air freight from remote areas to central laboratories, or even shipped internationally so that reference laboratories can double-check the original results. No matter the route or mode of transport, special packaging materials and trained professionals are needed to prevent spills or leaks that might pose a biosafety risk, and to preserve the quality of the specimen.
At the laboratory bench
Once a specimen safely reaches the laboratory, it must be quickly and accurately tested, and the results need to be shared back to clinicians, patients, and public health authorities. While diagnostic capacity for infectious diseases—including yellow fever—has rapidly expanded in recent years across Africa, laboratories continue to face a myriad of challenges, including inadequate stockpiles of essential supplies, inability to maintain and repair diagnostic equipment, and lack of quality control. During the COVID-19 pandemic, an explosion of public interest in diagnostics brought stakeholders together in new ways to address these issues, with solutions ranging from data sharing to dual screening for multiple diseases at once.
IDDS has worked to improve testing capacity at regional laboratories in countries like Ethiopia, Kenya, and Liberia, to bring diagnostics closer to potential patients and to reduce specimen transfer times and distance. “Diagnostics [are] now seen as a core component in strengthening future pandemic preparedness,” wrote global health experts Emma Hannay and Madhukar Pai. “While this is much-needed progress, it is critical to ensure that diagnostics are not just used during outbreaks.”
Delivering clear public health messaging
Engaging the community is key at all junctures of the “response pathway” but especially when sharing health information to drive behavior change. Public health messages must be culturally appropriate and delivered by trusted sources if community members are to take actions to stop the spread of the disease.
Cisse’s decision to visit the young mother and refer her to the community health center meant that the woman received timely supportive care and did not develop severe yellow fever. Her diagnosis also prompted the Kadiolo health district to conduct community outreach about the disease and the importance of vaccination. Supported by IDDS and the district’s World Health Organization advisor, this effort reached 920 people and likely saved many lives.
Going international
As witnessed during the COVID-19 pandemic, outbreaks can spread very quickly across international borders. The final key to effective outbreak response is for national health systems to also report into international databases, which allows policymakers at the local, national, and international levels to make informed decisions. One reporting system is GLASS, or the Global Antimicrobial Resistance and Use Surveillance System—the World Health Organization’s database for tracking the drug-resistance of microbes that can cause serious diseases. It gives clinicians and health officials crucial information on matching the right drugs to infections, but GLASS is only as accurate as the information coming into the database. IDDS has equipped five national health systems, Cameroon, Ethiopia, Kenya, Liberia, and Tanzania, to report into GLASS. To prevent the next pandemic, additional investments in disease surveillance—and training on how to use existing systems more effectively—are urgently needed.
