Community-Based Surveillance of Infectious Diseases: A Systematic Review of Drivers of Success

"Ultimately, the evidence largely points towards drivers of success that map closely to principles of participatory community engagement..."

Community-based surveillance (CBS), which involves engaging community members to detect and report events of public health significance within their own communities, is intended to complement facility-based systems, particularly in rural areas within low-resource settings. This article offers a systematic review and narrative synthesis of the evidence describing the drivers of success of CBS systems.

The researchers searched for peer-reviewed literature via MEDLINE, EMBASE, Global Health, SCOPUS, and ReliefWeb and carried out grey literature searches using Google Search and DuckDuckGo. The time range of publication was January 1 2012 to February 7 2022. Nineteen sources (17 peer-reviewed and 2 grey literature) met inclusion criteria. Included sources reported on CBS in 15 countries (including 3 conflict settings), none of which were in high-income settings. Sources evaluated CBS for detection and reporting of: buruli ulcer, COVID-19, Ebola virus disease, guinea worm, malaria, polio, and multiple infectious diseases.

Success factors fell broadly into 4 categories:

1. CBS workers (often community health workers) - Successful CBS was believed to be associated with community acceptance of the CBS workers that was, in turn, associated with their recruitment (e.g., having the community nominate the CBS workers or recruiting CBS workers from within the community) or with having nested CBS within an existing emergency response system that itself had good acceptability (which, in turn, was attributed to active participation and collaboration with communities). Trust between CBS workers and the community was also described as a key success factor. Success was also attributed to high motivation of CBS workers, who appreciated contributing to bringing good health to people, feeling a sense of service to the community, and increasing ties and trust with other community members. Training and supervision were also described as important, as was CBS worker proximity to communities.
2. Community - Communication and engagement were the most frequently cited success factors of CBS. For example, in Ethiopia, CBS workers organised village coffee ceremonies at which they were able to ask for reports of acute flaccid paralysis (AFP) - a proxy for polio - and discuss signs, symptoms, and reporting. Also, several CBS systems relied on the recruitment of community informants who would report suspect cases to CBS workers.
3. Case detection and reporting - Successes relating to data collection included: dynamic (i.e., adapted and improved) use of case definitions; the implementation of quality assurance procedures (i.e., data were regularly reviewed for accuracy and completeness); and rapid, real-time data-driven decision-making. The use of technology for data collection and reporting was generally reported as a challenge, though two sources referenced successful use of technological solutions.
4. Integration - Effective vertical integration of CBS with different actors along the reporting pathway (e.g., from communities, to the health facility, to the regional/national surveillance system) and lateral integration between the CBS system and other components of the surveillance system at, or close to, the same operational level (e.g., laboratory services, operational partners) were identified as success factors. For example, in Niger, an extensive polio surveillance system was scaled to include active case finding and reporting of COVID-19.

Reflecting on the findings, the researchers acknowledge that building genuine community participation into the design and implementation of infectious disease surveillance is time consuming and resource intensive. However, this "review has highlighted that many of the key drivers of success of CBS map to the principles and best practices of community participation, including: enabling and emphasising community ownership; committing to meaningful engagement and bilateral information exchange; involving a diverse group of community informants; recognising and enabling the desire, and competency, of community members to help themselves; and ensuring that systems are designed to build on the trust and goodwill within communities. These drivers of success were manifested not only in observed community acceptance (evidenced, for example, in 94% of community members agreeing to a physical examination for buruli ulcer in one study) but were also cited as contributors to the overall success of the CBS programme [Ed.: footnote numbers were removed from this quoted material]."

The researchers endorse do-no-harm approaches to CBS, which require careful consideration of the operational context and acknowledgment that CBS may not always be feasible or appropriate. (In some settings, a more effective and efficient approach to surveillance preparedness may involve bolstering the capacity of facility-based systems while increasing their accessibility and working to develop community confidence and trust.)

In conclusion, the study's "findings - insofar as they emphasise the benefits of meaningful community participation - suggest that developing CBS preparedness is more likely to be both successful and sustainable within communities that are actively engaged in designing and implementing a range of co-produced public health solutions. As such,...the emphasis of CBS preparedness should be on investing in community participation approaches in health more broadly - to enable the leveraging of this approach in an emergency - rather than on investing exclusively in siloed public health functions such as CBS."