Table 1.

Pacific syndromic surveillance system: system components and attributes.

	System components
System structure	Supported by WHO and SPC (including training); support at all levels of government; implementation manual ‘Practical guide for implementing syndromic surveillance in Pacific Island Countries and Territories 2010’ (World Health Organization and Secretariat of the Pacific Community 2010); sentinel sites generally based at major hospitals or health clinics; national focal-point for syndromic surveillance (responsible for tallying, analysing data, identifying outbreaks, initiating outbreak investigation and reporting).
Case ascertainment	Standardised case definitions of four core syndromes (influenza-like-illness – ILI, diarrhoea, prolonged fever and acute fever with rash); a fifth ‘syndrome’ is for unusual events; optional addition of syndromes at the local level; cases generally identified by doctor but occasionally by nurses or health information clerks.
Data collection and analysis	Paper-based (encounter forms, patient registers and logbooks) or electronic reporting mechanisms; guidance provided on analysis; threshold identification.
Reporting	Weekly reporting to WHO (including zero reports); unusual events reported immediately; regular feedback at the local level to surveillance sites and in-country stakeholders; weekly consolidated Pacific syndromic surveillance report sent to stakeholders via PacNet listserv (also made available on SPC and WHO websites).
Outbreak investigation and response	Thresholds for investigation; outbreak responses generally based on ‘Pacific outbreak manual’ (World Health Organization and Secretariat of the Pacific Community n.d.) or customised local outbreak manual; standard outbreak investigation steps; further detail on cases collected in the event of an outbreak; rapid local responses but provision of accessible public health advice or assistance from WHO and/or SPC on request.
	System attributes
Simplicity	Based on the tallying and reporting of cases that meet four syndromic case definitions; does not require laboratory confirmation; high training needs due to staff turnover; perceived as a simple system by users.
Flexibility	Range of approaches implemented by PICTs; adapted from early pandemic influenza surveillance system and other earlier systems; includes a ‘fifth syndrome’ which captures unusual events; PICTs are able to include additional syndromes based on local needs.
Acceptability	Participants increased from 6/22 to 20/22 during the period November 2010 and September 2011; informants agreed that the system was useful and an improvement on previous systems; 84% of sites reported during the review period; assists PICTs in meeting their International Health Regulations (IHR) obligations.
Data quality	Variable data quality with some discrepancies between clinical diagnostic data and captured syndromic data; no regular data quality checks; training in the use of thresholds to be implemented in the next training round; high visibility case definitions improved case ascertainment accuracy.
Sensitivity	In areas where sentinel sites had been implemented, the system is sensitive enough to detect outbreaks; in remote areas or areas without sentinel sites, outbreaks could be missed.
Timeliness	Ninety one percent (575/631) of reports were received on time (weekly); rapid identification of increases in cases as based on syndromes rather than laboratory confirmation.