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The effectiveness of public health surveillance systems in Chikungunya: a systematic review protocol

Review question/objective The objective of the proposed systematic review is to critically analyze currently available research studies and present the best available evidence related to the effectiveness of public health surveillance systems used in detecting and monitoring Chikungunya (CHIK). Background The emergence of CHIK epidemics worldwide poses a serious public health issue. CHIK is a debilitating mosquito‐borne Alphavirus accountable for the unexpected exponential rise in epidemics of febrile arthralgia in the past decade. A term used to address either the virus or the disease, CHIK is a Makonde word from Tanzania and Mozambique that means “that which is bend up” and refers to the stooped posture of patients suffering from CHIK‐induced joint pain.1 Chikungunya virus (CHIKV) infection may be traced as far back as 1779, in a 'Knokkel‐koorts' (a Dutch word meaning knuckle or joint) febrile epidemic, as recorded in the logbook of the Dutch physician, Dr David Bylon, in Batavia, Dutch East Indies (present day Jakarta, Indonesia).2,3The first modern case of CHIKV infection in humans was reported in 1952‐1953 at Tanganyika, East Africa4,5, while the first reported CHIK outbreak occurred in Bangkok, Thailand in 19586followed by a decade long epidemic in India from 1963 to 1973.7While there were no further epidemics for 30 years, the CHIK epidemics re‐emerged from 2004 onwards.8The people of Kenya, specifically in the area of Lamu province and the city of Mombasa, were hit by the CHIK epidemic9and this was soon followed by a series of epidemics that affected many areas around the Indian Ocean10, including the La Reunion Island, where 266,000 (38.2%) of the population11,12were infected and the Union of the Comoros, where more than 225,000 people were infected.7The epidemic reached India, affecting millions of people from 2005 ‐ 2007.12As of 10 February 2014, autochthonous (originating where it is found) cases are found in 55 countries, including 25 countries in Africa, 19 countries in Asia, six countries in the Americas, two countries in Europe and three countries in the Oceania/Pacific islands.13Hence, there is a strong urgency in implementing effective management measures to prepare the affected countries and healthcare sectors for the prospect of future outbreaks. Public health surveillance has always been a foundational public health strategy and has existed since 3180 B.C., when there was “a great pestilence” during the rule of Pharaoh Mempses of the First Dynasty in Egypt.14Surveillance is defined as the collection, analysis and interpretation of surveillance data, leading to appropriate public health response.15,16It is a public health tool used by countries worldwide to perform numerous functions, including promptly detecting disease outbreaks, monitor the spread of the disease and put in place outbreak response measures.15 Surveillance systems or activities may be generally classified as disease surveillance, vector surveillance or the combination of both. Data on CHIK disease cases which meet the possible, probable and confirmed case definitions are targeted for disease surveillance whereas vector surveillance addresses data on CHIKV vectors, mainly Aedes (Stegomyia) aegypti (Linnaeus) and Aedes (Stegomyia) albopictus (Skuse). Another classification is based on the activeness of surveillance, passiveness or the combination of both. Active surveillance includes hired surveillance officers playing an active role in connecting with healthcare entities for the consolidation of surveillance data, compared to passive surveillance that depends on the mandatory passive reporting of data submitted by healthcare institutions.17These surveillance systems may be administered geographically based on the hierarchical order of country, regional, province, district, locality or enumeration.18 Many countries that have experienced outbreaks and reported individual cases due to CHIK in the past, developed surveillance systems on the national and sub‐national levels with the overall objective of decreasing CHIK transmission and improving public health decision‐making with up‐to‐date epidemiological surveillance reports. However, these surveillance systems implemented may come late with much room for improvements, hence lowering their effectiveness in the early detection of outbreaks, as seen from studies during the 2006 epidemics in La Reunion Island and India. The French authorities from La Reunion Island took about a year to realize the severity of the CHIK epidemic, before initiating response and control strategies. By then, the people in La Reunion reportedly felt a sense of “neglect and abandonment.”19In India, the World Health Organization (WHO) reportedly failed to trigger an alarm on the CHIK transmission and lacked active support to the country. Also, there was a delay in the implementation of surveillance, with a surveillance system only put in place nine months after the first reported CHIKV infection. A complex interplay of factors, including surveillance, might explain the millions of infections and tens of thousands of deaths from the 2006 epidemic in India.20 As eradication of CHIKV has not been possible, a continued circulation of CHIKV during inter‐epidemic periods is present. This increases the crucial role of surveillance to help detect CHIK cases that may often go unnoticed or are misdiagnozed. Vulnerable regions such as Kenya and Malaysia are continuously exposed to these diseases, with the detection of CHIKV seropositivity among humans in Kenya21and the CHIKV seropositivity among healthy Malaysian adults in localities which have no history of CHIK outbreaks.22A consistent surveillance of cases including the inter‐epidemic periods is beneficial to profile CHIK epidemiology and disease trends and more accurately estimate the national burden of CHIK disease.23‐29 Although a WHO global strategy for dengue prevention and control for 2012‐2020 has been formulated, there is no similar document from WHO to approaching CHIK prevention and control.30There is also uncertainty regarding the performance and usefulness of surveillance systems currently implemented to detect and monitor CHIK. Hence, there is an urgency to evaluate the effectiveness of surveillance systems in alleviating the burden of the infections nationally and globally.31,32