Defining collaborative surveillance to improve decision making for public health emergencies and beyond

The COVID-19 pandemic and other large-scale infectious disease outbreaks, such as cholera, measles, and mpox (formerly known as monkeypox), are part of a global pattern of public health emergencies occurring with increasing frequency, magnitude, and complexity, compounded by devastating natural disasters, conflicts, and other humanitarian crises.1, 2, 3, 4 These events require the provision of timely and effective intelligence to decision makers (eg, policy makers, public health officials, communities, and individuals), so they can understand and reduce risks, prepare effectively, and establish response actions to minimise impacts on communities, economies, and health systems.⁵ Developing this intelligence requires robust surveillance capabilities interconnected with decision making and response capacities; however, public health emergencies repeatedly expose weaknesses in these capabilities, with numerous independent advisory and expert groups calling for bold changes.6, 7

In response to emergencies public health officers must consider many questions. For example, is this a true outbreak? How many cases and deaths did we have today? Who is most vulnerable? Are our health-care facilities coping? What variants are circulating here and how dangerous are they? Are our interventions effective and are they likely to succeed? Should we adjust our response, how, and what resources are needed? In most countries, the interoperability, agility, or analytical capabilities of data systems are inadequate to support the integration and use of these disparate data points to generate answers rapidly enough to support real-time decisions. Collaboration and integration are needed to address this challenge and strengthen disease surveillance. For many countries, however, progress on implementation has been slow, or existing integrated systems were not fully equipped to answer the wide range of questions raised during the COVID-19 pandemic, resulting in renewed calls for taking a more collaborative and integrated approach.6, 8, 9 Indeed, a National Public Health Institutes-led review into integrated disease surveillance (IDS) identified persistent challenges, including the fragmentation of existing evidence and lack of universal clarity on the definition and purpose of IDS and challenges in governance, financing, institutional structures, and the public health workforce capacity.¹⁰

To address the challenges posed by the COVID-19 pandemic and other health emergencies, WHO member states are driving changes on multiple fronts, with the support of international organisations and partners. First, by strengthening governance structures, including negotiations to amend the International Health Regulations (IHR 2005), and by developing a WHO convention, agreement, or other international instrument on pandemic prevention, preparedness, and response (WHO CA+).11, 12 Second, by bolstering financing for sustainable preparedness through the development of National Investment Plans, supported by funding partners where required, which includes the collaborative partnership forming the Pandemic Fund.¹³ Third, by strengthening the global architecture for health emergency preparedness, response, and resilience (HEPR).14, 15 The proposed framework for strengthening HEPR is constructed of five interconnected components that are underpinned by principles of equity, inclusivity, and coherence: collaborative surveillance, community protection, safe and scalable clinical care, access to countermeasures, and emergency coordination.14, 15 These components collectively aim to address the lessons identified from major health emergencies, while complementing the core capacities requirements defined by the IHR 2005, operationalising One Health, and supporting the implementation of regional and global public health strategies. Moreover, this framework prioritises the establishment of effective local and national surveillance as foundational for global public health security.

On May 22, 2023, WHO published Defining Collaborative Surveillance,¹⁶ the first of the five components for strengthening HEPR. This concept paper defines collaborative surveillance as “the systematic strengthening of capacity and collaboration among diverse stakeholders, both within and beyond the health sector, with the ultimate goal of enhancing public health intelligence and improving evidence for decision making” and proposes a conceptual model, key objectives, and supporting capabilities for countries.¹⁶ The objectives centre on the need to reinforce national disease, threat, and vulnerability surveillance; enhance laboratory and diagnostic capacities for pathogen and genomic surveillance; and establish collaborative capacities to predict, identify, and assess risks and monitor responses. Defining Collaborative Surveillance ¹⁶ highlights how collaboration is a fundamental capability in itself and sets out four key dimensions of collaboration (panel ).

Panel. Dimensions of collaboration for surveillance.

Across disease and threat surveillance systems

To enable a more comprehensive understanding of the epidemiological situation across systems for monitoring hazards, threats, and vulnerabilities

Across sectors

To foster collaboration across One Health partners, other non-health sectors (eg, education, transport, security, and industry), types of organisations, fields of expertise, and disciplines

Across emergency cycles

To ensure that surveillance capacities not only address routine monitoring and early warning of emerging events, but also deliver crucial information and intelligence throughout the cycle of health emergency prevention and risk mitigation, preparedness, response, and recovery

Across geographical levels

To ensure locally generated data are applied for timely local decisions to prevent, detect, and respond to local events and secondarily to facilitate the bi-directional flow of relevant data, information, and intelligence within and across all administrative levels where public health decisions need to be made; this depends on reinforcing equitable approaches to reporting, sharing, and feeding back to engender trust and enable all communities and all countries to benefit from surveillance activities, in turn strengthening global health security

This panel is derived from the Defining Collaborative Surveillance concept paper.¹⁶

Collaborative surveillance reinforces the need for the triangulation of multisource information for risk assessment and to inform decision making.17, 18, 19 No individual surveillance system can meet all required objectives. Moreover, the relative importance of each system and the information it generates varies over the course of the emergency cycle¹⁷, and often requires public health officers to look beyond their immediate systems to respond to decision makers' needs. Surveillance approaches must be carefully selected, well coordinated, strengthened, and integrated where possible to meet the full range of objectives for diverse hazards, as to construct the most appropriate constellation (or mosaic)²⁰ of systems for the local context and prioritised hazards.

The mosaic of surveillance systems will inevitably vary by context. Authorities must devise tailored solutions, which may include developing consolidated and interoperable systems to address multiple hazards in some settings, while supporting more flexible means of integration in others. Flexible modalities of integration can encompass cross-system sharing of data and information; sharing and integration of capacities (eg, workforce, systems, and infrastructure), while ensuring capacity investments can be applied to new and emerging threats; and open dissemination of surveillance findings where appropriate to enable intelligence exchange among diverse stakeholders and communities. During this tailoring of approaches, all surveillance stakeholders must recognise the value of IDS, vertical, and other specialised programmes working in unison within countries and across borders. Moreover, there is a fundamental need to improve collaborations with curators of data and insights (eg, context, community vulnerability, and capacity) not otherwise systematically captured by the traditional models of surveillance. Collaborative surveillance seeks to support and connect these systems and stakeholders and provide contextualised intelligence.

The collaborative surveillance concept identifies an ideal set of capabilities for public health decision making. Crucially, implementation of collaborative surveillance must remain grounded in country-driven evaluation, prioritisation, and resourcing of their surveillance systems, backed by aligned global public health community. Implementation will, however, be challenged by diversity across and within countries in their surveillance capacities, strength of collaboration across the four dimensions of collaborative surveillance, and the changing nature of evolving risks and hazards. Although success depends on establishing and maintaining enabling factors, including governance structures, sustainable funding for surveillance, a culture of trust, and a skilled and equipped workforce, for most countries, sizable challenges in these areas remain, requiring further attention. Additionally, there are gaps in tools and evidence to assist these processes for surveillance, such as the tools to comprehensively assess the maturity of countries' surveillance capabilities across multiple systems and actors. And there are evidence gaps to sufficiently inform what combination of approaches can most effectively and efficiently deliver the full range of decision maker needs for diverse emergency-prone hazards and contexts. In unison with progressively reinforcing existing national, regional, and global surveillance strategies by establishing collaborative surveillance capabilities, the global public health community must address these gaps to build a more robust global architecture for HEPR against current crises and future major health emergencies.

We all contributed to the collaborative surveillance concept paper¹⁶ that is discussed in this Comment. We declare no other competing interests. This Comment represents the personal opinion of the authors and not that of the organisations for whom they work.