COVID-19 surveillance in Democratic Republic of Congo, Nigeria …

Summary of findings

Disease surveillance systems are developed for the monitoring of the health status of populations and most importantly for early detection of infectious diseases outbreaks and prompt intervention. Surveillance is a top priority in management and control of any pandemic. Countries’ responses to emergent health crises depend mainly on the strength of the surveillance systems they establish [36]. This study aimed to document the COVID-19 surveillance strategies adopted by DRC, Nigeria, Senegal and Uganda in response to the COVID-19 pandemic as well as to describe the strengths, weaknesses, and lessons learnt about the existing surveillance approaches adopted during the epidemic. Furthermore, the aim of the study was to gather evidence on functionality of the adopted surveillance so as to inform the enhancement of surveillance systems to facilitate preparedness for future epidemics in Africa.

Surveillance for COVID-19 cases was risk-based across all four countries and involved a combination and networking of several surveillance methods. It was found that all countries had previous experiences with managing surveillance systems in an epidemic situation such as Ebola disease and were therefore, able to respond promptly to the pandemic but insufficiently due to resource constraints. For example, the national Emergency Operation Centre (EOC) in Nigeria had been in existence and had ample experiences in polio as well as in Ebola outbreak surveillance and response. The key strengths across the studied countries included leveraging on these previous outbreak experiences and pre-existing functional surveillance systems, strengthened surveillance capacity at sub-national levels by training rapid response teams at subnational levels; establishment of databases with capacity to report on key indicators on COVID-19 response, including electronic systems linked to DHIS-2 which contributed to regular review and update of surveillance policies and strategies. Developed countries on the other hand have standardized surveillance response system with skilled technical staff.

All four countries adopted realtime and active contact tracing as one of the essential surveillance approaches so as to control the disease through empowering decision makers with information on the health-related behaviors of their communities and the spread of the COVID-19 disease in the community. This enables the governments of the study countries to intervene quickly to stop the spread of disease. The priority groups for contact tracing included high-risk persons such as contacts of confirmed cases, and travelers from countries with reported COVID-19 cases, but prioritization was revised to include only symptomatic contacts and travelers, as the pandemic progressed. Furthermore, contact tracing was decentralized at a later time to target individuals at higher risk of severe disease.

The key challenges and gaps included; inadequate human resources for surveillance activities especially at lower levels; insufficient space for institutional quarantine and isolation; low case detection rates; limited capacity for routine genomic sequencing of variants; weak decentralized surveillance capacity; insufficient infrastructural capacity for quarantine and isolation; weak health care infrastructure including inadequate funds and tools for surveillance activities; misinformation and poor public perception about COVID-19, especially on social media. For example, inadequate human resources limited the optimal performance of surveillance systems. This was corroborated by the overwhelming load of contact tracing workload for healthcare workers reported in other studies where Uganda had 186/100,000 population and Nigeria had 111 per each state with populations in millions [25]. There was also humanitarian assistance from donors such as WHO, UN baskets, non-govermental organizations and the Nigerian indigenous Coalition against COVID-19. The world bank provided funds for contact tracing and Africa Centres for Disease Control and Prevention funded active case search.

Inadequate human resources and other challenges moderated the gains that would have accrued from adapting already existing surveillance systems and experience in managing outbreaks. The UK support initiative and Clinton health access initiative supported state and local capacity building and ongoing vaccine development.

As the pandemic progressed, the resources available could not cope with upsurge in activities required to maintain standard operating procedures leading to modifications in surveillance strategies. The criteria for testing and contact tracing were streamlined to reduce the workload. Isolation and quarantine facilities were expanded to private facilities with the implication of poorer follow-up and monitoring. Furthermore, all countries reported gaps in data management and surveillance response at subnational levels. The importance of task shifting to community health workers, adopting technology based solutions, strong national leadership including enhancing multisectoral partnership to respond to the pandemic was adopted. The countries prioritized national-level coordination of the various surveillance approaches across sectors and stakeholders. Each country established or leveraged robust partnerships with non-governmental organizations, academics, and other global institutions. These countries improved data management and surveillance capacity rapidly by training health workers and increasing resources for laboratories, but the disease burden continued to be under-detected.

Results in context of the literature

A key objective of the World Health Organisation’s COVID-19 surveillance is to guide the implementation and adjustments of COVID-19 control measures including isolation of cases, contact tracing and quarantine of contacts [37]. The experience of African countries in handling previous infectious disease outbreaks and the existing surveillance infrastructure were helpful and in part made Africa fare better in COVID-19 pandemic compared to the high-income countries [38]. The exising surveillance infrastructure was revitalized and repurposed for COVID-19 surveillance. The surveillance methods documented in this study was corroborated by a systematic review of COVID-19 surveillance systems in 13 other African countries which documented the similar surveillance methods reported in this study [21]. Some variations however, exist in the level of implementation of the surveillance strategies between the countries which determines to a large extent, the representativeness of the systems. South Africa with more comprehensive surveillance system reported more representative COVID-19 burden data compared to countries such as Tanzania and our four study countries where COVID-19 surveillance strategies were poorly developed [21]. The interpretation of the morbidity and mortality burden from COVID-19 is subject to the quality of the surveillance system adopted. The surveillance systems in the four African countries under study have been generally non-representative of the entire underlying population. The seroprevalence surveys conducted in these countries reported a much higher COVID-19 prevalence than would be expected by the number of cases reported.

Therefore, there is a need for these countries to utilize multiple surveillance approaches to understand the full picture of the disease burden. The risk based testing strategy adopted by the countries underestimated the burden of COVID-19 due to underreporting. Extending COVID-19 testing to all contacts of a confirmed case would give a better sense of the disease burden but this attracts high cost which the countries may not have the capacity to afford and sustain. Hence, additional sources of data may be needed for example from mortality surveillance, and community surveys which were not fully integrated. A study in Zambia found significant excess mortality due to COVID-19, with the majority of deaths occurring in the community that were undiagnosed, while many deaths at the facility were also un-tested prior to death [39]. Mortality surveillance and all-cause mortality tracking has generally not been widely practiced in many African countries. Uganda attempted to establish a mortality surveillance system and has been conducting post-mortem surveillance for hospital and community COVID-19 deaths, but this has remained weak due to challenges in mortality reporting in the health systems. In Nigeria, the serological surveys conducted confirmed much higher COVID-19 prevalence than reported through the regular surveillance system, thereby emphasizing the importance of using multiple surveillance methods.

Implications for epidemic preparedness and response

During the epidemic these countries made efforts to upgrade and upscale the health systems infrastructure so as to improve resilience and to enhance rapid response to infectious diseases emergencies.

Generally, all the four countries started planning early and had a fairly slow buildup of COVID-19 cases. The study revealed the existence of a emerging framework for surveillance structure and system in the four countries. At the onset of the pandemic, all four countries under study had in place limited existing surge capacities mainly in the areas of laboratory testing and trained epidemiologists with limited dedicated funds for outbreak response management such as contact tracing. Nigeria, Senegal and Uganda all reported having dedicated budgets for outbreak response which were available at the beginning of the outbreak for provision of personal protective equipment and limited contract tracing [35].

The existing surveillance systems in all the countries were built to respond to localised epidemics whereby the central level response team would support the decentralized rapid response team (RRT) at the outset of an outbreak. However, the subnational structures have never been activated into full preparedness response mode. At the same time the countries were never prepared for simultaneous country-wide outbreak response in multiple geographic locations. In the event of a widespread pandemic such as COVID-19, all countries experienced challenges in subnational responses including shortages in adequately trained surveillance officers, data analyst and contact tracers. Building the capacity of subnational epidemic response capacity requires substantial resources allocation including funding, training staff, and equipping the decentralized centers. Due to resource constraint, a strategy adopted by the countries was to prioritize the districts or regions at highest risk i.e., geographies with higher number of cases. For example, in the DRC, surveillance efforts were strongest in Kinshasa which was the epicentre of the epidemic and where mass testing centres and several diagnostics laboratories were established.

There was deliberate modification in the daily schedule of human resources in communities and at health facilities to reduce their work load and lessen the risk of contracting COVID-19 [12]. Furthermore, countries did not have the appropriate number of responders. For example, there was a lack of adequate contact tracers to match the pandemic demand across all countries. In addition, the study countries still have challenges with ensuring the availability of adequate and appropriately skilled human resource, a situation that preceded the pandemic and that will require strategic resourcing during and after the COVID-19 pandemic. The countries could rapidly train, repurpose, and deploy community-based voluntary health workers (VHW) and facility-based health workers, but these structures require additional strengthening for epidemic preparedness and rapid response.

Overall, analysis and use of surveillance data for action existed at the central/national level but was limited at the subnational levels in all the studied countries. Ensuring timely data availability and use of data is critical to public health decision making. During the pandemic crisis we observed the importance of having the right data which was routinely used for EOC guidance. Therefore, countries had strategies to report data daily, weekly and monthly. The study countries in various degrees adopted electronic systems from paper-based to improve efficiency of data transmission and data use for decision making. Availability of surveillance data contributed to regular review and update of the existing surveillance policies, strategies and standard operating procedures. However, there were notable gaps in data accuracy and consistency at non-sentinel sites than at sentinel sites. Furthermore, the data were not disaggregated by socio-demographic characteristics such as sex, location/place of residence to show burden at the individual level characteristics. The establishment of databases linking surveillance with testing that were accessible to key stakeholders improved communication and efficiency. Data systems development and use require improvement at the subnational levels for more efficient response.

Technological innovations were deployed to enhance surveillance activities including contact tracing, monitoring persons in quarantine, reporting, data analysis, laboratory results return, with improved efficiency. For example, Senegal adopted and used digital communication innovations such as the “Alerte Santé Sénégal” app and “Sunucity” which is an incident reporting app for suspected COVID-19 cases from community that allows feedback from the authorities [12]. These need to be evaluated and replicated.

Strengthening partnerships is key for epidemic preparedness and response. The studied countries were able to source initial supplies with support from non-governmemtal organizations, philanthropists and international partners. The private sector provided funding for testing kits and built facilities for quarantine and isolation services as a surveillance measure. However, the countries need to optimize the public private partnerships in several areas including provision of health services and manufacture of health products. South-to-South COVID-19 response collaboration and technical support can be fostered as a result of the countries’ differential experience. For example, Nigeria and Uganda with expertise in capacity building for epidemic preparedness among responders can be a resource in this area in the region.

Furthermore, there is a need for the improvement of the alert management systems for identification of COVID-19 cases or any other epidemic disease from the community. Senegal, Nigeria and Uganda, reported using call centers with toll free lines to support case identi.fication and contact tracing. However, these call centers were eventually overwhelmed and response became suboptimal as the pandemic progressed with widespread community transmission. Routine alerts could be supplemented with other active surveillance approaches such as systematic health facility surveillance, mortality surveillance and periodic surveys for better estimation of the burden of disease and disease outcomes.

Study limitations

A substantial part of this study relied on document review. At times the codified evidence in guidelines, policy documents and scientific publication may differ from the real world experience or may lag behind on what could be happening on the ground. Thus, the extent to which the documents reviewed reflected the true practice is uncertain. However, the study mitigated this potential bias by triangulation the literature review information with the qualitative interviews.

This study did not assess the relative performance or effectiveness of surveillance methods. Surveillance methods adopted in the countries studied were complementary. In the face of resource challenges, there is a need to adopt the most comprehensive and cost-effective methods. For example, the European Centre for Disease Preventiion and Control recommended for member countries no longer testing mild suspected cases of COVID-19 should integrate COVID-19 surveillance with sentinel surveillance of influenza-like illness or acute respiratory infection [40]. The swabs obtained at the sentinel sites would then be tested for SARS-CoV-2 in addition to influenza virus. This provides some cost saving by using existing resource framework.

The article showed that private sector contributed immensely to COVID-19 response such as surveillance and testing, treatment, risk communication, health promotion and maintenance of access to essential health services.