ReviewCritical issues in implementing a national integrated all-vaccine preventable disease surveillance system☆
Introduction
Surveillance is the foundation of sound public health practice; however, disease surveillance systems are often fragmented and vertical, based on the characteristics of the targeted disease or syndrome, and the characteristics of the existing public health infrastructure. To address the need for surveillance for vaccine preventable diseases (VPDs), in 2007, the World Health Organization published the Global Framework for Immunization Monitoring and Surveillance (GFIMS), which outlines measures that ministries of health may take to enhance national VPD surveillance [1]. The GFIMs emphasizes that VPD surveillance should be integrated and placed in a ‘unified framework’ that builds upon the strengths of existing surveillance systems rather than being implemented as new disease-specific and vertical systems. The main goal of an integrated VPD (iVPD) surveillance system is to prevent duplication of activities that are common to all surveillance systems and at the same time to minimize human resource and supply expenditures. Global immunization partners viewed the GFIMS as a welcome framework, at a time when multiple new and underutilized vaccines were entering developing world markets. These new products are costly compared with existing Expanded Programme on Immunization vaccines, and their introduction must be prioritized among other health interventions. In addition to providing routine vaccination program monitoring information, iVPD surveillance data may demonstrate disease impact through a streamlined system that minimizes redundancy and is beneficial and efficient. Enhanced integrated surveillance systems could potentially assist in reaching multiple disease surveillance objectives while providing quality data for decision makers at national and international levels. Building these systems upon the existing national communicable disease network will ideally strengthen surveillance for all communicable diseases of public health importance.
Despite the recommendation from the World Health Organization (WHO) and major partners for expansion of VPD surveillance and immunization program monitoring, countries continued to struggle to implement efficient iVPD surveillance systems even after the GFIMS had been developed and widely distributed, as it did not provide operational guidance for implementation. Few countries had experience in iVPD surveillance systems apart from febrile rash illness surveillance to detect measles and rubella in the Americas [2], [3]. The most developed VPD surveillance system globally is the acute flaccid paralysis network, a highly sensitive, but vertical, single disease surveillance system for the detection of poliomyelitis [4]. Examples of other stand-alone systems include regional, sub-regional or national surveillance for influenza-like illness, sentinel site surveillance for meningitis in Africa (Pediatric Bacterial Meningitis [PBM] surveillance) [5], sentinel surveillance for invasive bacterial disease in the Americas (Sistema Regional de Vacunas [SIREVA]) [6], and the global rotavirus surveillance network [7]. Thus, while public health experts believed that iVPD surveillance was a more economic and efficient system, little was known about how to develop and implement a practical and relevant iVPD surveillance system, which surveillance components could feasibly be integrated, and what the programmatic and financial benefits of integrating surveillance for multiple VPDs would be.
The GFIMS’ call for the development of iVPD surveillance was timely, given the increasing availability of vaccines for diseases caused by Streptococcus pneumoniae (pneumococcus), rotavirus, influenza virus, and human papilloma virus (HPV) in the developing world. Furthermore, the increased uptake of underutilized vaccines such as Haemophilus influenzae type b (Hib) vaccine and regionally important vaccines such as Japanese Encephalitis (JE) and Yellow Fever (YF) vaccines further highlighted the need for strengthened or new surveillance to estimate the local burden of disease and monitor the impact of vaccine introduction [8].
New vaccine introduction generally involves significant expense [9]. For example, in addition to the purchase of new vaccines for the routine immunization program, expansion of existing cold chain capacity and enhancement of other vaccine delivery logistics typically require substantial investments. What was less clear; however, was how to develop quality surveillance necessary for diseases targeted by new vaccines, how to link it with existing vertical disease surveillance systems, and how much additional investment will be required for the system. In 2007, immunization experts at the US Centers for Disease Control and Prevention (CDC), WHO Headquarters and the Pan American Health Organization (PAHO) began to discuss the feasibility of integrating surveillance for multiple diseases. Critical issues related to the potential benefits and limitations of integration were addressed, including which diseases were candidates for integration, which surveillance components could feasibly be integrated, and ways to integrate laboratory and data management activities. We present the process that went into developing operational guidance for ministries of health and the lessons learned in consideration of preparing generic guidelines for integrated “all-VPD surveillance” for countries to adapt to their national circumstances. This is the first time that this process has been undertaken for the integration of VPD surveillance, and while we do not present data from an in-country implementation, our experience may be helpful to countries considering embarking on this type of work. This CDC and PAHO collaboration has led to opportunities to pilot the generic protocol in the Americas.
Section snippets
Conceptual development of integrated surveillance
At the onset of the process, it was not known how an integrated product for surveillance would be structured or whether it was a realistic goal within a national context. Before identifying the critical issues to be addressed and the requirements for developing an all-VPD surveillance system, it was important to reach consensus about the definition of the word “integration” in the context of VPD surveillance. “Integrate” is defined as “to form, coordinate, or blend into a functioning or unified
Requirements for pilot project
To identify a country to pilot the surveillance integration, we identified key requirements (Fig. 1). As previously noted, clear interest and agreement by the national ministry of health, with a commitment to sustainability with national funds and only modest donor support was critical. Since the system was to include surveillance for diseases prevented by new vaccines, a pilot country needed to have early adoption of one or more new vaccines as well as existing laboratory capacity. In
Implementation and the way forward
The next step in the integration process was to implement the protocol at a national level to learn the extent to which the integration could be achieved within an established system. With technical assistance from CDC and PAHO, the Costa Rica Ministry of Health began the implementation process in 2008 [12]. Toscano and colleagues have detailed the incremental costing of the implementation of the project [13], and lessons learned by Costa Rica's experience will provide key information on the
Acknowledgements
Brent Burkholder, Umesh Parashar, Cynthia Whitney, and Nancy Messonnier for support in initiating this project. Jon Gentsch, Susan Reef, Paul Rota, Cristiana Toscano for review of the protocol.
Conflict of interest: No authors have reported a conflict of interest.
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The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.