Enhancing outbreak early warning surveillance in resource-limited Pacific island countries and territories

Comprehensive, timely, and accurate health data are essential for the detection of outbreak-prone diseases. If these go unnoticed or are identified late, they pose significant risks to the health of a population. In the Pacific islands, a syndrome-based surveillance strategy, known as the Pacific Syndromic Surveillance System (PSSS), is employed for the early detection of outbreaks. The PSSS, implemented in 2010, has provided a mechanism by which resource-limited Pacific island governments have been able to perform routine surveillance activities and address many of their national and international health protection needs and obligations. Despite being a cornerstone of health protection for many Pacific islands, the surveillance system had not been comprehensively evaluated. Nor had behavioural, technical, or upstream health system factors that influence its performance been investigated. This thesis assesses whether the PSSS is meeting its stated objectives and produces evidence to augment technical and operational elements of the system. The thesis answers the following questions: (i) is the PSSS meeting its stated objectives? (ii) are algorithm-based approaches to outbreak detection appropriate in the Pacific island systems and context?; (iii) how can the PSSS be enhanced to meet information needs during public health emergencies?; and (iv) what factors enable and constrain surveillance nurses’data collection and reporting practice? The thesis found that the surveillance system is simple, well regarded, trusted, and context-relevant mechanism that Pacific island governments from across the development spectrum have been able to adopt and maintain with minimal external technical or financial support. Despite these positive findings, the research identified several statistical, procedural, and broader systems barriers to optimal performance, including chronic staffing and other resource constraints, insufficient data on which to base outbreak detection analysis, and poor integration of health information systems. Looking ahead, the thesis identifies practical opportunities for system improvement and highlights areas for further research