Use of electronic tools for evidence-based preparedness and response to the COVID-19 pandemic in the WHO African region

The investigation of a cluster of cases of pneumonia by Chinese health authorities in December, 2019, in Wuhan City, Hubei province, China, identified a novel coronavirus (severe acute respiratory syndrome coronavirus 2 SARS-CoV-2), as the causative agent.1WHONovel coronavirus (2019-nCoV): situation report 1. World Health Organization, Geneva2020Google Scholar During the subsequent worldwide spread, SARS-CoV-2 first arrived on the African continent in February, 2020, with cases identified in Egypt and Algeria.2WHO Regional Office for AfricaA second COVID-19 case is confirmed in Africa.https://www.afro.who.int/news/second-covid-19-case-confirmed-africaDate: 2020Date accessed: July 3, 2020Google Scholar As of July 20, 2020, over 600 000 confirmed cases of COVID-19 have been reported in member states of the WHO African region.3WHONovel coronavirus (2019-nCoV): situation report 133. World Health Organization, Geneva2020Google Scholar Although there have been rapid developments in testing for COVID-19, outbreak response actions of case investigation and contact tracing are most effective when implemented before widespread community transmission.4US Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): when to initiate case investigation and contact tracing activities.https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/when-to-investigate.htmlDate: 2020Date accessed: July 3, 2020Google Scholar These actions require robust disease surveillance systems. Herein, we discuss some of the digital tools currently in use in the WHO African region to support preparedness for and response to COVID-19. Building on the experiences and lessons learned in responding to major crises, such as Ebola in west Africa and the Democratic Republic of the Congo, the WHO identified data and information management as crucial to preparedness and response to COVID-19. Key areas included management of epidemiological data, epidemic intelligence, risk assessment, response planning, monitoring and evaluation, epidemic modelling, outbreak analytics, research and scientific writing, and the development and dissemination of information products. Using a readiness checklist and consultative engagements with WHO Country Offices, Ministries of Health, and partners, the WHO identified areas that needed additional strengthening, capacity building, and digital tools. An agile software development approach was adopted to iteratively develop and deliver simple electronic data collection and reporting tools to member states, which were continually reviewed as new data and guidelines on COVID-19 became available. Herein, we describe five examples of such tools. The first is the Epidemic Intelligence from Open Sources (EIOS), which is used by the WHO Regional Office for Africa (AFRO) for media monitoring and scanning of various online media and sources for unverified rumours and reports referencing COVID-19, along with verified alerts reported by member states directly. As of July, 2020, 163 unverified COVID-19 signals reporting potential COVID-19 outbreaks were identified and followed up with member states for verification. The COVID-19 pandemic was initially detected by AFRO in nine countries using media sources on the EIOS platform. The Nigeria Centre for Disease Control and Ugandan National Ministry of Health have adopted EIOS as one of their routine media monitoring tools to provide early warnings and alerts of acute public health events.5WHO Regional Office for AfricaWHO supports Nigeria to become first African country to adopt new epidemic intelligence tool.https://www.afro.who.int/news/who-supports-nigeria-become-first-african-country-adopt-new-epidemic-intelligence-toolDate: 2019Date accessed: July 3, 2020Google Scholar, 6UN Global PulseUsing radio broadcasts to augment early detection of health risks.https://www.unglobalpulse.org/project/using-radio-broadcasts-to-augment-early-detection-of-health-risks/Date: 2019Date accessed: July 3, 2020Google Scholar The second tool includes the outbreak toolkit combined with R templates for epidemiological analysis. A suite of tools were developed in accordance with WHO Global COVID-19 Surveillance Guidelines and Protocols to assist member states in case data collection, reporting, analysis, and interpretation. This suite of tools in the toolkit allows timely monitoring of the COVID-19 outbreak situation in settings where skilled human resource capacity remains scarce. Risk assessment and rapid analysis of the COVID-19 situation in the African region have also been facilitated by combining the tools provided in the outbreak toolkit with R packages developed by the R Epidemics Consortium. The COVID-19 outbreak toolkit is publicly available through the WHO AFRO website, and consists of: (1) an electronic COVID-19 data collection form; (2) a data summarisation tool; (3) a contact tracing tool; (4) a COVID-19 line listing template with a data dictionary; (5) a risk assessment tool; and (6) resources for the WHO Go.Data outbreak investigation tool. These tools have been adapted for both monitoring the pandemic across the region and within countries, and also to aid evidence-based public health decision making. The risk assessment tool has been widely disseminated and used for assessing both the transmission patterns of COVID-19 at subnational levels and the effectiveness of public health measures, such as physical distancing. This tool has been adopted by nine countries, and is supporting the routine review of public health strategies and strengthening interventions in high-risk areas or at local hotspots. Additional statistical and epidemiological analyses resulting from the use of this open-source software ensure that public health leaders and decision makers are provided with real-time information on the evolution of the pandemic. The third tool is Go.Data, which is an integrated solution for the management of data on cases, laboratory results, contacts, contact tracing, and daily follow-ups, and facilitates management of contact tracing teams. This tool has numerous built-in visualisations. Provided free to the Ministries of Health, Go.Data supports an unlimited number of users and features a web-based platform for configuration, data entry, and data visualisation, as well as a mobile application for Android and Apple (iOS) platforms, allowing easy data entry in the field. Virtual training sessions for Go.Data have been attended by 19 countries in the African region. In Gabon, Go.Data has been used to manage data for over 3500 cases of COVID-19 and trace over 4200 contacts. The adoption of Go.Data is affected by several factors, including the use of alternative systems, strained internal capacities to introduce and scale a new tool, and insufficient availability of funds to support its deployment to peripheral levels of the health system. The fourth tool is the early warning, alert, and response system (EWARS). Ensuring early detection of individuals with COVID-19 is crucial for preparedness and operational readiness. For SARS-CoV-2, existing tools are being used to manage surveillance data. EWARS-in-a-box is a tool that has been used to support the Integrated Disease Surveillance and Response (IDSR) strategy in the WHO African region. Deployed during an emergency as an adjunct to the national disease surveillance system, EWARS-in-a-box contains all the equipment needed to establish surveillance and response activities, particularly in difficult and remote field settings without reliable internet or electricity. Recent examples of use in such settings include in humanitarian emergencies in South Sudan, conflict-affected north west and south west regions of Cameroon, and in Borno State in North East Nigeria, and in support of recovery efforts after tropical cyclones Idai and Kenneth in Mozambique. EWARS continues to support IDSR data management in these locations, with COVID-19-specific reporting features that have been integrated into the platform. This tool has also been specifically adopted for COVID-19 screening in Cameroon. The final tool is an online geographic information system dashboard for situation appraisal and decision making. An interactive COVID-19 GIS dashboard has been created to allow visualisation of updated clinical, epidemiological, and contextual information in the 47 countries of the WHO African region, and it provides a snapshot of the situation in the continent and worldwide. WHO has also supported the creation of similar online dashboards for Sierra Leone, Republic of the Congo, Democratic Republic of the Congo, and Liberia, allowing the easy display and retrieval of important data on COVID-19 in Emergency Operations Centres. As of June 28, 2020, more than 91 million requests were made using the online elements used to build the regional dashboard and the dashboard itself, with an average of 498 050 requests per day. Information generated by these various electronic tools is used in the WHO Daily COVID-19 Update and the Weekly External COVID-19 Situation Report, as well the Weekly Bulletin of Outbreaks and Other Emergencies, all of which are widely disseminated to member states, donors, and partners. In conclusion, the early detection of alerts and cases of COVID-19, together with the identification and follow-up of contacts, are high priority strategies. The WHO AFRO, national authorities, and partners continue to work towards enhancing surveillance measures to assist member states in taking specific public health actions to slow the spread of this virus.7El-Sadr WM Justman J Perspective: Africa in the path of COVID-19.N Engl J Med. 2020; (published online April 17.)https://10.1056/NEJMp2008193Crossref PubMed Scopus (131) Google Scholar The use of available surveillance data to inform decision making and interventions in real time is an important component of an effective outbreak response.8Polonsky JA Baidjoe A Kamvar ZN et al.Outbreak analytics: a developing data science for informing the response to emerging pathogens.Philos Trans R Soc Lond B Biol Sci. 2019; 37420180276Crossref PubMed Scopus (87) Google Scholar All of the tools discussed here have some functionality offline (eg, by means of local storage), however, an adequate internet connection is required to upload and submit collected data. Internet connectivity can be challenging in remote locations, however, platforms such as Go.Data have applications that are compatible with mobile phones that use cellular data packages rather than the internet. Data management capability and capacity in the WHO African region remains weak, hampering the ability of affected countries and the region as a whole to accurately report the data needed to guide decision making during the course of an outbreak. Improvements in this area are needed so that data collection during outbreaks is accurate, and can be scaled up easily, be analysed effectively to inform response actions, and bring a rapid end to disease transmission. However, achieving these outcomes requires investments to build and sustain strong national and regional public health capabilities, infrastructure, pre-service and in-service training sessions for personnel, and operational processes.8Polonsky JA Baidjoe A Kamvar ZN et al.Outbreak analytics: a developing data science for informing the response to emerging pathogens.Philos Trans R Soc Lond B Biol Sci. 2019; 37420180276Crossref PubMed Scopus (87) Google Scholar For more on the COVID-19 outbreak toolkit see http://outbreaktoolkits.rsis.afro.who.int/covid-19For more on the R Epidemics Consortium see https://www.repidemicsconsortium.org/resources/For more on Epidemic Intelligence from Open Sources see https://www.who.int/eiosFor more on the WHO Go.Data outbreak investigation tool see https://www.who.int/godata/aboutFor more on the geographic information system dashboard see https://arcg.is/XvuSXFor more on the early warning, alert, and response system (EWARS) see https://www.who.int/emergencies/surveillance/early-warning-alert-and-response-system-ewars For more on the COVID-19 outbreak toolkit see http://outbreaktoolkits.rsis.afro.who.int/covid-19 For more on the R Epidemics Consortium see https://www.repidemicsconsortium.org/resources/ For more on Epidemic Intelligence from Open Sources see https://www.who.int/eios For more on the WHO Go.Data outbreak investigation tool see https://www.who.int/godata/about For more on the geographic information system dashboard see https://arcg.is/XvuSX For more on the early warning, alert, and response system (EWARS) see https://www.who.int/emergencies/surveillance/early-warning-alert-and-response-system-ewars We declare no competing interests. All authors contributed significantly to the work, and fulfil criteria listed for authorship. BI, OK, and FMb conceptualised this project. OK provided guidance on the direction of the Comment. BI, OK, GSW, BF, and CMW made substantial contributions to the initial versions of the manuscript. BI, GSW, RN, FMo, TML, AB, TM, PN, AM, AT, FK, KA, and FMb contributed to the information gathering and synthesis. AF, OK, BF, GSW, CMW, and BI provided key input on the content and structure of the manuscript. All authors contributed to the revision process, and reviewed and approved the final version of the manuscript to be published.