Box 17.2Situational Awareness Constraints in Low- and Middle-Income Countries

Perhaps the greatest challenge in epidemic and pandemic response is the timely identification and notification of the first pandemic case. However, low- and middle-income countries are substantially slower than high-income countries to identify and communicate infectious disease outbreaks (Chan and others 2010). In most outbreaks, the first (or index) case is found retrospectively. Reporting delays result from multiple factors, which are discussed here. Moreover, the epidemiological characteristics of the index case often are difficult to ascertain, particularly in settings with limited diagnostic and laboratory capacity.

Patients infected with potentially pandemic pathogens may present with nonspecific symptoms, making discriminating between endemic and novel or significant pathogens difficult unless differential diagnostic tools are available. Gaps in health system access and surveillance system coverage also hamper identification and reporting. In such cases, an incipient epidemic will be identified only after sufficient deaths have occurred to draw the attention of health authorities. Particularly in areas where health system gaps are significant, monitoring unofficial sources of information, including rumors, may be useful (Samaan and others 2005).

Even once a potentially unusual or significant case has been identified, delays can be caused by low statistical capacity, low data management capacity, and low communication capacity among local frontline health workers. Delays also can arise from how surveillance and reporting systems are designed—for example, if health workers routinely report potentially significant cases at the end of the month rather than when they are identified.

Another constraint arises from inconsistencies in real-time reporting of data. During an outbreak response, national and regional health authorities must have strong relationships with local health providers to understand how data are generated and reported at the clinical level. Robust monitoring and data validation procedures, such as the use of global positioning systems and case-based systems, along with positive incentives for correct reporting, may help to alleviate such problems (Mancini and others 2014).

From: Chapter 17, Pandemics: Risks, Impacts, and Mitigation

Cover of Disease Control Priorities: Improving Health and Reducing Poverty
Disease Control Priorities: Improving Health and Reducing Poverty. 3rd edition.
Jamison DT, Gelband H, Horton S, et al., editors.
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