A Community-Centred Approach to Global Health Security: Implementation Experience of Community-Based Surveillance (CBS) for Epidemic Preparedness

"When effectively engaged and when there is trust in the systems and providers, the community itself can mobilise for disease control activities."

Epidemics and pandemics, such as Zika, measles, cholera, Ebola Viral Disease (EVD), and COVID-19, begin within a community. In resource-poor settings, communities may not be aware of the potential threat posed by the illness, have limited access to health facilities, delay care-seeking, and/or lack trust and confidence in the government - any of which can result in poor motivation to notify authorities. Community-based surveillance (CBS) is a tool to improving early detection of outbreaks that the International Federation of the Red Cross and Red Crescent Societies (IFRC) and country National Societies (NS) (hereafter, RC/RC) has used in many of the 192 countries in which it works. Since 2019, the RC/RC has been delivering the Community Epidemic and Pandemic Preparedness Programme (CP3), an initiative to build community-level epidemic and pandemic preparedness with a One Health approach encompassing both human and animal diseases. This paper reports on the CBS component of CP3 as applied in high-risk zones of 4 of the 8 countries in which CP3 has been used to date: Indonesia, Kenya, Sierra Leone, and Uganda.

Building capacity, trust, community participation, and engagement, as well as a reliable response network, are key components of the work. RC/RC volunteers are a wide network of lay community members based within their own villages who, through their RC/RC training, motivate their local community with participatory health education and activities to improve health and disease prevention practices. The focus is on improved preparedness rather than response. The RC/RC CBS system applies mobile phone technology that can be deployed with limited infrastructure under a wide range of conditions. Volunteers submit reports by short message service (SMS), applications (apps), or electronic forms for real-time-automated data processing. Reports can be designed for very basic analogue phones or smartphones and used by people with no experience and minimal literacy.

A 3-tiered model of CBS was developed for CP3 (see below) drawing on experience and lessons learned by RC/RC and other organisations. It is grounded in the concept that communities are the change agents in global health security, but they can only effectively fulfil that capacity if they are engaged, skilled, and enabled to:

• Identify risks and implement practices to prevent epidemic diseases;
• Recognise potential disease events ("alerts") using community case definitions (CCDs) and notify authorities; and
• Take early action to control disease spread.

The article describes implementation of the model in-country beginning in June 2018. In brief, volunteers are selected from within their own communities, with criteria for diversity and representation of the local sub-population groups in terms of gender, ethnicity/tribe, languages, and literacy. They connect with relevant community focal points (e.g., traditional healers, religious leaders), facilitating health literacy and positive behaviour change in their locality and reporting CBS alerts. People with influence in the community can be selected as "CBS informants" who connect with CBS volunteers if they encounter unusual or severe illnesses; this approach increases reach and embeds the process with local ownership.

Through a process described in the article, CBS volunteers are trained to use technology for rapid notification and instant recording in electronic systems, depending on the network, resources, and existing tools employed and preferred in each locality. They are given a booklet with job aids of community health messages and supporting actions (e.g., thorough handwashing techniques). Supervisors are provided with a database of volunteers and villages in their catchment zone and with the Kobo app, which contains the standardised CBS form, on their own smartphone or project-provided phone or tablet. Numerous measures are put in place to manage volunteers and monitor results throughout implementation.

Some of the CBS volunteers' work that is explicitly communication-centred is related to prevention and health literacy. Activities and messages vary by locality to target the priority diseases and behaviours but in general comprise: house visits, group sessions, orientation for traditional healers and leaders, mobile cinema, public campaigns, environmental cleanup, school activities, radio messages, setting up handwashing stations, and oral rehydration salts (ORS) distributions. For example, in Kenya, Uganda, and Sierra Leone, response to potential measles alerts focused on promotion of vaccination, communication of signs and symptoms, and mobilisation of students at schools for vaccine uptake.

Using tables and graphs, results of the process are shared in terms of prevention and health literacy, coverage, accuracy and validity, timeliness, and response and action. For example, from January to December 2019, CBS volunteers achieved 392,576 instances of contact with people in the target areas and conducted 70,162 house visits and 547 school health activity sessions; 17 radio shows were broadcast. In addition, a high degree of accuracy and timeliness were demonstrated. Furthermore, there is close proximity and direct contact between volunteers and supervisors, as well as supervisors and local officials, so timely action is relatively easy to accomplish.

As reported here, in the face of the coronavirus pandemic, the CBS design in CP3 has incorporated a new CCD for COVID-19 into the alert system, and volunteers have been trained on the new alert SMS code, key messages, and prevention activities. One lesson learned is that resources required to revise the materials and refresh volunteers' training can be a limiting factor to adaptability.

Other challenges/takeaways from the CP3 experience include:

• Zero reporting by weekly SMS is a simple, low-cost, low-workload means of assuring that volunteers remain engaged and that the CBS system is sustained. However, zero reporting rates often take some time to reach satisfactory levels as volunteers settle into their role, requirements and processes.
• When communities raise alerts to CBS volunteers, they expect a response. A lack of sufficient response mechanism to CBS alerts not only interferes with the impact but can undermines the community's trust and confidence. This can result in the failure to report illnesses, rumours and misinformation, and threats to volunteers.
• Open and clear discussion about what CBS can and cannot do are needed.
• Sustainability is a major consideration in the CBS system design.
• Countries spent 4-8 months at inception to liaise and adapt the programme design with government ministries, communities, and other key stakeholders. Though time-intensive, this process reportedly led to better partnerships with a foundation of trust, as well as capacity building among volunteers and communities. "It is intended that such knowledge and skills will remain in communities as the funded programme phases out, with communities, RC/RC branches, and sub-regional health and veterinary structures empowered to take action."

In conclusion, this review has shown "the positive results and feasibility of routine preparedness CBS systems in high-risk zones to prevent outbreaks and epidemics....The experience and results at this stage of implementation illustrate that communities themselves are capable of early detection and early action. They have changed attitudes and practices for disease prevention, used new technology and software, and taken effective immediate actions to care for the sick and contain disease spread....CBS is capable of reducing outbreaks and minimising infectious disease mortality and morbidity" when it is based in community engagement, stage-wise capacity building, monitoring and response actions, and collaborative relationships with stakeholders.