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JIPH-1429; No. of Pages 9 ARTICLE IN PRESS

Journal of Infection and Public Health xxx (2020) xxx–xxx

Contents lists available at ScienceDirect

Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Epidemiologic surveillance for controlling Covid-19 pandemic: types,

challenges and implications
Nahla Khamis Ibrahim a,b
a
Professor of Epidemiology at Community Medicine Department, King Abdulaziz University, Jeddah, Saudi Arabia
b
Professor of Epidemiology at Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: The objectives of the study was to determine the types, challenges and implications of surveillance meth-
Received 5 May 2020 ods for controlling Covid-19 pandemic. An integrative article review was done. The source of data were
Received in revised form 5 July 2020 documents from WHO, Euro-surveillance, CDC, Saudi CDC, MOH, and journals from PubMed, Medline, etc.
Accepted 13 July 2020
The inclusion searching criteria were surveillance, Covid-19, types, benefits and challenges, during the
period 2005−2020. Published studies, reviews and guidelines that determined these criteria were col-
Keywords:
lected. Data extraction and analysis were completed for all included articles. A critical appraisal was done
COVID-19
based on the University of Michigan Practice Guideline’s levels of evidence. The final sample for the inte-
SARS-CoV-2
Pandemic
grative review comprised 30 studies. Results revealed that types of Covid-9 surveillance includes routine
Surveillance surveillance (comprehensive, case-based, and aggregated weakly methods), active, wildlife, syndromic,
Types sentinel and sentinel-syndromic methods. Laboratory and hospital-based surveillance are another impor-
Challenges tant types. Help-lines, surveys, participatory electronic, digital and event-based surveillance are relatively
Implications new cost-effective methods. Many surveillance indicators can be calculated. Timely and accurate of
Indicators surveillance data is an essential element for effective Covid-19 interventions. Regarding challenges, the
quality of surveillance in developing countries is constrained by resources and training. The main lim-
itations of surveillance are under-ascertainment/under-reporting, lack of timeliness and completeness
of surveillance data. In conclusion, surveillance is a cornerstones for controlling Covid-19 pandemic.
Enhancing Covid-19 surveillance is vital for rapid cases detection, containing spread & ending pandemic.
© 2020 Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Additional aims at the national levels are to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1- Comprehensive routine surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2- Case-based routine surveillance (reporting) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3- Aggregated routine surveillance (reporting) (10, 13, 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
At the national level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Weekly number of each of the followings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4- Active surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5-Syndromic (clinical) surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
- A probable case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6- Sentinel surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7- Sentinel syndromic surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

E-mail address: [email protected]

https://doi.org/10.1016/j.jiph.2020.07.019
1876-0341/© 2020 Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
implications. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.019
G Model
JIPH-1429; No. of Pages 9 ARTICLE IN PRESS
2 N.K. Ibrahim / Journal of Infection and Public Health xxx (2020) xxx–xxx

Laboratory based surveillance: it contains 3 types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

10- population serological surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
11- Hospital-based surveillance for SARI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
12- Routine surveillance of nosocomial outbreaks and outbreaks in long-term care facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
13- Enhanced surveillance of hospitalized cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
14- Mortality surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
15- Health care surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
16- Surveillance of wildlife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Media, electronic and digital types: (it includes 4 types) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
18- Electronic reporting systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
19- Digital surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
20- Event-based surveillance (29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
II- Surveillance indicators and implications in controlling Covid-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
III- Challenges & limitations facing Covid-19 surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
B- Limitations of Covid-19 surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Limitation of the review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
The strengths and weaknesses of sources of the article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Introduction application of preventive and control measures [10]. In spite of

the efforts for enhancing epidemiological surveillance, developing
Currently, the whole world is straggling and facing the era of nations still have difficulty in accurate identification, diagnose, and
eco-epidemiology. There is emerging and re-emerging of numerous reporting such communicable diseases [11].
devastating infectious agents. The emerging viral zoonotic diseases A study conducted using a susceptible-exposed-infectious-
outbreaks are growing in number. Severe Acute Respiratory Syn- removed (SEIR) model to estimate Covid-19 epidemiological
drome (SARS), H5N1, influenza A / H1N1 pandemic, and Middle parameters before the implementation of preventive measures in
East Respiratory Syndrome Coronavirus (MERS-CoV) are among Wuhan, China. Results revealed that if the measures had been
such infections. All of these infections and others had serious public started 1, 2, or 3 weeks earlier, the cases could had been reduced
health implications [1]. by 66%, 86%, and 95%, respectively [12], These findings magnify the
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV- importance of surveillance in controlling Covid-19.
2) causing Covid-19 is one of the most important devastating There are many benefits for applications of sensitive surveil-
emerging infectious diseases, nowadays. Covid-19 was classified lance system for controlling and ending Covid-19 pandemic.
as a public health emergency of international concern (PHEIC) on However, there are challenges for its application, especially in the
30 January 2020 [2]. Then, it was characterized as pandemic by the developing countries. Limited number of state of arts were con-
WHO on March 11, 2020. SARS-CoV-2 was also classified as “Risk ducted about Covid-19 surveillance. So, such review is urgently
Group 3” pathogens as it carries a very big risk to the community required.
due to its effect on health and the global economy [3,4]. Covid-19 The objectives of the study was to determine the types,
pandemic leaves huge devastating burdens on health, lives, econ- challenges and implications of surveillance methods used for con-
omy, with restriction of the whole populations’ societal activities trolling Covid-19 pandemic.
worldwide [5,6]. It causes a global health and economic crisis; with
countries shutting their borders and issuing travel bans, closing
schools and businesses, imposing strict quarantines, and more [3]. Methods
Several factors participated in occurrence of Covid-19 pan-
demic. Firstly, the global spread of the new SARS-CoV-2 (without An integrative review was conducted. The method of the current
previous human exposure or immunity). Secondly, SARS-CoV-2 as integrative review included articulation of the problem regarding
an RNA virus exhibits high mutation rates that allow rapid diver- surveillance of Covid-19, completion of a well-defined literature
sification at the cost of generating non-viable descendants [3]. In search, evaluation of the quality of data, analysing data, and pre-
addition, the virus transmission rate or its basic reproduction num- sentation of conclusions. The first step is a clear identification of
ber (R0 ) is high [4]. Furthermore, up to date, no effective treatment the problem epidemiological surveillance and Covid-19. Literature
nor vaccine exists for Covid-19 [3]. search was clearly addressed subjects such as search terms, the
The cornerstone of any prevention and control measures is the sources used, and the inclusion and exclusion criteria. The sources
epidemiological surveillance. Surveillance is “the ongoing system- of information were documents from WHO, Euro-surveillance,
atic collection, analysis, interpretation and dissemination of data CDC, Saudi CDC, MOH and journals through search on PubMed
regarding a health-related event; for doing actions”. Surveillance & Medline. The search included surveillance, Covid-19, magni-
is a critical part of public health practice [7]. Real-time analyses tude, indicators, challenges, and benefits (implications). Regarding
of epidemiological data are urgently required for increasing the the inclusion criteria, published guidelines, reviews, studies that
awareness about the problem and for prompt interventions [8]. assessed surveillance system and surveillance in Covid-19 during
Identification of the newly suspected or confirmed Covid-19 cases the period from 2005 throughout 2020 were selected. Other arti-
is an essential element for effective public health interventions, and cles were excluded. For evaluating, grading quality of the included
for prevention of future pandemic [9]. articles, the University of Michigan Practice Guideline’s levels of
Covid-19 surveillance involves monitoring the spread of the evidence Evidence-Levelling Hierarchy was used for grading of
disease in order to identify the patterns of progression, and for evidence. In the data analysis process, data are ordered, catego-

Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
implications. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.019
G Model
JIPH-1429; No. of Pages 9 ARTICLE IN PRESS
N.K. Ibrahim / Journal of Infection and Public Health xxx (2020) xxx–xxx 3

Table 1
A summary of reviewed surveillance articles.

Author, year Objectives Methods Level of

evidence

1. Helmy YA, et al. 2020L. [1] To provide the most recent information about SARS-CoV-2. Review D
2. Rodriguez-Morales AJ, et al, To summarize the clinical, laboratory, and image features, outcome of, risk factors, A systematic review and A
2020. [2] and comorbidities of COVID-19 confirmed case (from current available meta-analysis
observational studies).
3. Schröder I. COVID-19: 2020. To explore why COVID-19 is able to progress to a global pandemic that affects our Review D
[3] daily lives to an extent not known in recent history.
4. Sohrabi C, et al. 2020[4] To summarize the current state of knowledge surrounding Covid-19 WHO review D
5. Kummitha RKR. 2020[5] To determine how governments in China and Western democracies differ in their Review D
technological response to control the transmission of the pandemic.
6. Bong C–L, et al. 2020. [6] To outline the problems facing all countries in response to Covid-19, especially Review D
those with serious economic and health resource challenges, and possible ways to
address them.
7. Ibrahim NK, Al Bar HM. To assess health facilities’ performance and health workers’ knowledge of Quantitative, cross-sectional C
2009[7] surveillance activities for childhood vaccine-preventable diseases. analytical study
8. Sun K, et al. 2020. [8] To describe efforts to compile and disseminate epidemiological information on Quantitative, Population-level C
COVID-19 from news media and social networks. observational study,
9. Fan C, et al. 2020[9] To estimate the distribution and scale of the migrants residing in Wuhan after they Quantitative, B
returned to their hometown communities in Hubei Province or other provinces Quasi-experimental analysis
after the 2019-nCoV outbreak.
10. WHO. 2020. [10] To update Covid-19 case definition, define transmission pattern, revise the Guideline D
definition of a contact and update on global surveillance with aggregated data
reporting
11. Prieto JT, et al. 2017[11] To evaluate the quality and characteristics of electronically collected data, the user Quantitative, Follow-up study B
acceptability of the symptom reporting platform, and the costs of running the
system and of identifying ILI cases, and to use the collected data to characterize
cases of reported ILI.
12. Ricoca Peixoto V, et al. To present and discuss early evidence on under-ascertainment of COVID-19 and its Review D
2020[12] motifs, options for surveillance, and reflections around their importance to tailor
public health measures.
13. ECDC; 2020.[13] To purpose an updated strategy for COVID-19 surveillance at national and EU/EEA Report from Euro-surveillance D
level that specifically aims to reconcile the data needs for effective pandemic
response with what is still feasible in countries and within healthcare systems
under siege, while taking into account guidance issued by the World Health
Organization
14. WHO. 2020. [14] To provide an overview of surveillance strategies that Member States should WHO’s report D
consider as part of comprehensive national surveillance for COVID-19.
15. Spiteri G, et al. 2020 [15] To give details about the epidemiology of the first European cases of Covid-19. Quantitative, Retrospective C
study
16. Pung R, et al. 2020 [16] To report data for the first three clusters of COVID-19 cases in Singapore, the Quantitative, Prospective C
epidemiological and clinical investigations done to ascertain disease cohort
characteristics and exposure types.
17. CDC. 2020 [17] To monitor the spread and intensity of the pandemic, to enable contact tracing to CDC’s report D
slow transmission, and to identify disease clusters, to understand severity and
spectrum of disease, identify risk factors and methods of preventing infection.
18. Pal M, et al. 2020 [18] To update the history, genetics, epidemiology, modes of transmission, Report D
pathogenicity, clinical features, laboratory diagnosis, public health implications,
economic impact, treatment, control, and prevention of SARS-CoV-2.
19. Udugama B. [19,2]. To summarize the current known biological properties of SARS-CoV-2, diagnostic Report D
tools and clinical results for detecting SARS-CoV-2, emerging diagnostics, and
surveillance technology to curb the spread.
20. CDC. 2020. [20] To highlights guidance and recommendations for evaluating and identifying CDC report. D
patients who should be tested for COVID-19
21. Zwald ML, et al. 2020 [21] To conduct rapid Sentinel Surveillance for COVID-19 — Santa Clara County, Quantitative, Follow up, B
California, March 2020 Experimental study
22. de Lusignan S, et al. 2020 To identify whether there is undetected community transmission of COVID-19, Quantitative,Experimental B
[22] estimate population susceptibility, and monitor the temporal and geographical study
distribution of COVID-19 infection in the community.
23. Eurosurveillance 2020. [23] To provide regularly updated information on coronavirus disease-2019 (COVID-19) Guideline from D
Eurosurveillance
24. Ng Y, et al. 2020. [24] To analyse the first 100 COVID-19 patients in Singapore to determine the Quantitative,Follow-up study C
effectiveness of the surveillance and containment measures. (retrospective)
25. Saudi MOH, SCDC, 2020. To provide guidance on COVID-19 surveillance in healthcare and community Guidelines of Saudi CDC and D
[25] settings and enhance rapid detection of confirmed COVID-19. MOH
26. Domeika M, et al. 2009 [26] To present the introduction process of the electronic surveillance system for Quantitative, Intervention B
communicable diseases ULISAS in Lithuania. study
27. CDC. 2020 (4). [17] To improve public health surveillance builds on prior progress inside and outside CDC Review. Booklets series D
CDC.
28. Mahmood S, et al. 2020 [28] To provide several cases for infection control, home-based diagnosis and Review D
screening, empowerment through information, public health surveillance and
epidemiology, and leveraging crowd-sourced data.
29. WHO. 2020. [29] To provide an overview of surveillance strategies that member States should Guidance document by WHO D
consider as part of comprehensive national surveillance for COVID-19.
30. Louis MS. 2012. [30] To propose a vision for improving access to and sharing of data useful for public Report arise from MMWR. CDC D
health surveillance, identify challenges and opportunities, and suggest approaches
to attain the vision.

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rized, and summarized into a combined and integrated conclusion. is losing opportunity of early diagnosis of many Covid-19 cases,
Finally, conclusions of reviews was reported in a table. Analysis of and no measures will be applied for them or for their contacts. This
different sources was done & presented in three main themes: The can lead to more spread.
first one summarizes the aims and types of surveillance, the second
one is about the indicators and implications, and the third part is 3- Aggregated routine surveillance (reporting) (10, 13, 14)
about challenges and limitation of Covid-19 surveillance. Table 1
demonstrates a summary of the reviewed surveillance articles. It For understanding the epidemiology and trends of Covid-19, all
summarize the 30 most suitable articles on surveillance. countries are required to provide the following minimum set of
aggregate counts once weekly.
Results
At the national level
I Aims and types of global Covid-19 surveillance
Weekly number of each of the followings
a. Aims of Covid-9 global surveillance (according to WHO & CDC) a- newly confirmed cases, b- newly case-deaths from Covid-
are to [13,14]: 19, c- new cases hospitalised due to Covid-19, d- newly confirmed
cases discharged, e- newly confirmed cases tested for Covid-19 by
1 M̈onitor trends of the Covid-19 where human to human trans- age-group in years, f- newly confirmed deaths by age-group in years
mission occurs. [13].
2 Rapid detection of new cases in countries where the virus is not This type of surveillance can be easily applied in most of the
circulating; countries, even the poor, either by its own or by the help of other
3 Provide epidemiological information to conduct risk assessments agencies. Again, the drawback of such type, if applied alone, is the
at the national, regional and global level. loss of diagnosis of many cases.
4 Provide epidemiological information to guide preparedness and For the 3 routine types, countries should report on a case-
response measures. by-case basis as far as possible, but in case of limited resources,
5 Monitor viral changes to inform drug and vaccine development, aggregate weekly reporting is also possible [10,13].
and to identify markers of severe infection”.
4- Active surveillance
Additional aims at the national levels are to
It deals with active search for the disease in a certain popula-
1 Detect and contain nosocomial outbreaks to protect healthcare tion. WHO recommends such type of surveillance for case finding,
workers and patients. testing, and contact tracing in all transmission cases. All countries
2 Detect and contain outbreaks in long-term care facilities and need to quickly strengthen Covid-19 active surveillance for fast
other closed communities to protect those most at risk of severe recognition of the infected persons, and to allow prompt isola-
disease and poor outcomes. tion and quarantine [5]. The overall aim of surveillance after the
first case of Covid-19 was to support the global strategy of con-
b. Types: there are many types of surveillance can be used in tainment measures with rapid identification, follow-up of cases,
Covid-19 [13]: minimizing transmission [15] and prevent clusters from spreading
Routine surveillance: It includes 3 types (Comprehensive, case- [16]. Contact and co-exposure identification is done for all recog-
based, aggregated routine surveillance) [13,14]. nized possible cases [15]. It is expected to monitor epidemiological
trends, rapid detection of the new cases, conduction of risk assess-
1- Comprehensive routine surveillance ment, and guiding for disease preparedness [10]. It supports the
affected individuals and warning their contacts in order to stop
This type of surveillance deals with complete testing of all sus- Covid-19 cycle of transmission. This surveillance type can be done
pected cases. It uses the rate of the number of newly confirmed by training public health workers and volunteers. Through training,
cases / 100,000 inhabitants. The advantage of this type is that it the contact tracers identified how to quickly locate and talk with
gives the most accurate indicator of Covid-19 intensity. Further- the affected individuals, assist with isolation issues, and identify
more, such type can measure the geographic spread, and severity close contacts and help those who need self-isolation [17]. Such
of COVID-19. This surveillance method can be also monitors trends type of surveillance is significant for nations which actively find
by time and compare between intra-country data [13]. The chal- the cases among contact [16]. In France, for example, contacts are
lenge facing the application of comprehensive surveillance is the traced from the date of onset of clinical symptoms in the index case
huge cost of testing all suspected cases, considering both the test- [15].
ing capacity, prices, manpower and safety [12]. So, it is impossible
to be applied low income, or developing countries. 5-Syndromic (clinical) surveillance

2- Case-based routine surveillance (reporting) It means surveillance of health data about the clinical manifes-
tations that has an important impact on health.
The WHO requests national authorities to report probable and As of March 2020, the WHO recommends Covid-19 Case defini-
confirmed cases of Covid-19 infection within 48 h of identification. tions as:
An update of the line-listing needs to be provided immediately - A suspected case:
as the outcome data being available, within 30 days of the 1st A. P̈atient with acute respiratory illness (fever & at least one sign
report [13,14]. This surveillance type can be applied by most of / symptom of respiratory disease as cough, shortness of breath),
the countries. Very low-income countries can apply such type with AND a history of travel to or residence in a location reporting com-
the assistance of the international organization as WHO or Non- munity transmission of Covid-19 disease during the 14 days prior
Governmental Organization (NGOs); for providing of laboratory to symptom onset¨;
kits, other facilities. The drawback of such type, if applied alone, OR

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B. Ä patient with any acute respiratory illness AND having been 19 are usually reported within 24 h of recognition. SARS-CoV-2
in contact with a confirmed or probable Covid-19 case in the last rapid antigen detection and antibody detection tests are also avail-
14 days prior to symptom onset¨; able [13]. Such methods are less costly, but less accurate, can be
used the developing countries.
OR The testing priorities in case of limited resources, while the
number of suspected cases exceeds the available testing capacity,
C. "A patient with severe acute respiratory illness (fever and at needs to be available for certain groups. These groups are healthcare
least one sign/symptom of respiratory disease, e.g., cough, short- workers visiting patients, elderly people, those with underlying
ness of breath; AND requiring hospitalization) AND in the absence chronic medical conditions who show signs of acute respiratory ill-
of an alternative diagnosis that fully explains the clinical presenta- ness, hospitalised patients with SARI in order to appropriate clinical
tion" management and all cases, even mild, who developing ARI in hos-
pitals, long-term care facilities or other vulnerable communities
[13].
- A probable case
9- Virological sentinel surveillance of Covid-19: Such surveil-
lance is based on using the clinical specimens that obtained through
A. Ä suspect case for whom testing for the Covid -19 virus is
national sentinel surveillance of ILI/ARI/SARI using RT-PCR [13].
inconclusive¨.
Both virological and virological sentinel methods are very
OR
important for confirmation of the case by RT-PCR. The drawbacks of
B. A suspect case for whom testing could not be performed for
these types is mainly related to cost of testing. Furthermore, both
any reason.
non-propagative and propagative virological testing for Covid-19
- A confirmed case:
must be conducted at laboratories using procedures equivalent to
Ä person with laboratory confirmation of Covid-19 infection,
bio-safety level 2 (BSL-2), and BSL-3, respectively [13]. Such levels
irrespective of clinical signs and symptoms¨.
of safety may be not available in low-income nations.
Laboratory confirmation is done using two samples of real-time
polymerase chain reaction (RT-PCR) through various clinical spec-
imens; mainly nasopharyngeal or oropharyngeal swabs. [18,19]. 10- population serological surveillance
The information taken from this surveillance is utilized for mak-
ing decisions about health policy and health education [13]. It helps In UK, for example, the health care practices contributing in
in rapid case detection by using the working case definitions. On virology surveillance collect blood samples from persons coming
the other hand, the confirmation of the cases need a big costs, and for a routine blood testing. They are asked to give an extra sample
laboratories with high bio-safety levels. for Covid-19 serology [22]. It is a very important type for the inten-
sity and distribution of the virus in the population. However, such
6- Sentinel surveillance surveillance type needs a huge cost, and usually can not applicable
in the low or moderate income nations.
A network of healthcare providers or hospitals are recruited to Hospital-based types: It is needed to identify risk groups for
regularly report data about a disease [13,20]. Reporting units with severe disease, measure impact and inform decisions on mitigation
a high possibility of seeing the cases, having good laboratory facil- measures [23].
ities, and a qualified staff were selected. Such type of surveillance It includes 5 types
is used for promptly understanding the magnitude of Covid-19 in
a certain population. Detection of such transmission is essential 11- Hospital-based surveillance for SARI
for notifying response actions, including testing criteria, quarantine
guide, investigation protocols, and community mitigation actions Nations which is no longer testing the mild cases of suspected
[21]. The drawback is that it is based only on the cases in sentinel Covid-19, must at least test all SARI patients admitted to hospital
health care facilities. and Intensive Care Unit (ICU) / High dependency Unit. These coun-
tries need to monitor the percentage of confirmed Covid-19 from
7- Sentinel syndromic surveillance all SARI. Sentinel hospitals need to be chosen if the catchment pop-
ulation is well recognized and stable. Another appropriate method
Nations which not testing mild suspected cases for Covid- is selection of all hospitals in a given area/region and use the inhabi-
19, but still encouraging such cases to consult their primary tants of this area as denominator [10,13]. Such surveillance method
healthcare providers (PHCP), including telephone consultations, can be applied for most of the countries. However, it has a drawback
must integrate Covid-19 surveillance with sentinel surveillance of late case detection, were it is primarily based on the symptomatic
of influenza-like illness (ILI) or acute respiratory infection (ARI). patients.
Swabs obtained by sentinel physicians from a systematic sampling
of cases presented with ILI/ARI need also be tested also for SARS- 12- Routine surveillance of nosocomial outbreaks and
CoV-2. In nations where sentinel physicians can’t swab the cases, outbreaks in long-term care facilities
self-swabbing and shipment of specimens through devoted chan-
nels can be utilized. The intensity of Covid-19 can be known from Infections can cause many outbreaks in hospitals. Covid-19
the weekly number of positive results over all tested specimens, nosocomial outbreaks must be notified within 24 h of detection
and / or the weekly number of confirmed cases over the number of (class I reporting). This surveillance leads to quickly manage such
ILI/ARI consultations [10,13]. The drawback is that it based only on events, enhancing infection prevention and control measures. It
the health care facilities. leads to contact tracing for protecting healthcare workers, patients
and residents (who are at high risk of severe disease and poor out-
Laboratory based surveillance: it contains 3 types come). In addition, such approach leads to preserving the essential
health-care infrastructure. At national level, the number of such
8- Virological (serologic) surveillance: It is done by using Covid-19 outbreaks and the proportion of affected facilities may be
molecular tests for Covid-19. Laboratory confirmed cases of Covid- used as supplementary indicators of intensity, geographic spread

Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
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and its impact on the healthcare system [10,13]. On the other hand, lation & follow-up of the contact and mild cases at home. It gives
the limitations of such type may be related to lack of timeliness or reassurance of the isolated cases as they are under supervision of
completeness of the report. consultants. However, many cases can be lost by this method.

13- Enhanced surveillance of hospitalized cases 18- Electronic reporting systems

In such type, the risk groups can to be recognized and It used web-based tools for reporting disease & epidemics [13].
followed-up through Covid-19 enhanced comprehensive or sen- Such surveillance can improve the quality and timeliness of the
tinel surveillance of the hospitalized patients [13]. For example, in surveillance. Electronic record dashboards, and other electronic
Singapore an enhanced Covid-19 surveillance was applied early by tools are needed to assist surveillance system [26]. American CDC
testing all patients with pneumonia, patients in ICUs, people who utilizes interactive Germ data dashboard, bio-informatics in the
died of unknown cause, and individuals with ILI in sentinel PHC cloud, application programming interfaces (APIs), Fast Healthcare
clinics. Suspected patients are also tested according to clinical or Interoperability Resources (FHIR), and SMART (Substitutable Medi-
epidemiological reasons [16,24]. Such surveillance is a very impor- cal Apps, Reusable Technology) on Fast Healthcare Interoperability
tant type to detect new cases. However, the case detection methods Resources (FHIR) apps to enhance the surveillance system [27].
were primarily based on the symptomatic patients [28]. In KSA, the Health Electronic Surveillance Network (HESN), estab-
lished in 2014, is utilized nowadays for rapid reporting, updating
14- Mortality surveillance and giving feedback about Covid-19 cases [25].

The surveillance is done for death among hospitalised confirmed 19- Digital surveillance
Covid-19, and elderly who die outside hospitals in long-term care
facilities. This type of surveillance remains a vital tool for measuring Many countries utilizes digital surveillance including apps, loca-
the disease severity. The surveillance data is also easy to collect, tion data and electronic tags in Covid-19 pandemic. In the USA, an
available and frequently updated. However, such mortality data ankle bracelet technology was used to enforce quarantine among
can’t mirror the correct Covid-19-related mortalities in the whole Covid-19 patients (avoid violation). Tracking wristbands can takes
population. [10,13]. the place of Smartphone apps. In South Korea, a GPS apparatus was
used to track the locations of isolated individuals for sending alerts
15- Health care surveillance to authorities if people leave the chosen areas. Hong Kong author-
ities requires a bracelet and an app for all travellers. In Singapore,
Such type notifies the effect of Covid-19 on the capability individuals have to report their locations with photographic proof.
of the healthcare system (acute and long-term care facilities). It Furthermore, Thailand is using an app and SIM cards for all trav-
gives information concerning the availability or lacks of essential ellers to enforce their quarantine. India is planning to manufacture
resources as hospital beds, ICU beds, ventilators, personal protec- location and temperature-monitoring bands. Social media search
tive equipment (PPE), and healthcare personnel shortages. It can indexes (SMSI) was used in China as an effective early predictor of
provide data that are timely, easy to interpret, and readily acces- Covid-19 outbreak. Such work can allow the health departments
sible [17]. WHO, other organizations, NGOs and rich countries can to locate possible and high-risk outbreak places [9]. Furthermore,
help low-income nations, according to their deficiencies, and based the crowd sourcing artificial intelligence tasks for a database of
on such surveillance reports. On the other hand, the limitations of Covid-19 was done in China. Research outputs compiles thousands
such type may be related to lack of timeliness or completeness of of research articles on SARS-CoV-2 & other coronaviruses [9,28]
the report. Regarding the cost-effectiveness, electronic and digital surveil-
lance may require a big budget at the start. Such budget is needed
16- Surveillance of wildlife for the running a telemedicine and for extensive training. [27–30]
However, the operational cost of running a telemedicine center can
It was needed at China for the identification and characterization be low compared to running primary care facilities or specialized
of possible reservoir and source of infection. Surveillance among hospitals (reduced hospital-acquired infections), and can reduce
people who are in contact with wildlife is important to recognize the economic burden on strained health care facilities and sys-
behavioural risk factors [1]. Surveillance of wildlife can prevent tems [28]. On the other hand, digital surveillance may be supposed
further pandemic if there banning of some food habits like eating to break the confidentiality, and human rights. Furthermore, it is
bats and others [25]. Dealing with wildlife may carry a high risks important for stakeholders to determine how to tackle the problem
of transmission of Covid-19, and many other infections. This type of fake news and misinformation (infodemic) [28].
needs the applications of high levels of bio-security. Improvement
of biosecurity regarding wildlife trade and closing wet markets in 20- Event-based surveillance (29)
China is important. (1)
The capacity to rapidly detect any changes in the overall
Media, electronic and digital types: (it includes 4 types) COVID-19 situation can be further strengthened through robust
event-based surveillance (EBS) mechanisms. EBS captures unstruc-
17- Help-lines, surveys, participatory surveillance: tured information from formal and informal channels such as
Nations which is also not routinely tested the majority of sus- online content, radio broadcasts and print media across all relevant
pected cases, and minimize the access to PHC need to use another sectors, to complement conventional public health surveillance
methods. Among these methods are consultations’ calls with sen- efforts. Successful EBS implementation requires dedicated human
tinel doctors, calls to health care telephone help-lines (at regional resources and clear processes to sift through large volumes of
or national levels), consultations of online health care apps or self- information to filter, triage, verify, compare, assess and com-
assessment tools for advice on Covid-19 testing [13]. This type municate relevant content. Numerous web-based systems have
can be applicable for the low-income countries due to low cost. been developed over the years to support EBS activities, many
It helps in decreasing the rate of hospital-acquired infection by iso- of which converge through the WHO-led Epidemic Intelligence

Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
implications. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.019
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Table 2
Summary of types and characteristics of Covid-19 surveillance.

Types of surveillance Description

Routine surveillance (3 types)

1- Comprehensive (mass) routine surveillance Complete testing of all suspected cases
2- Case-based routine surveillance Reporting cases of Covid-19 infection within 48 h of identification
3- Aggregated routine surveillance Weekly numbers of newly Covid-19 cases, deaths, etc.
4- Active surveillance Active search & contact tracing
5- Syndromic (clinical) surveillance Surveillance of health data about the clinical manifestations
6- Sentinel surveillance Healthcare providers or hospitals are recruited to regularly report
Covid-19 data
7- Sentinel syndromic surveillance: Intergradation of Covid-19 surveillance with sentinel surveillance of
ILI or ARI.
8- Virological surveillance Molecular testing of Covid-19 by PCR.
9- Virological sentinel surveillance Using clinical specimens obtained through national sentinel
surveillance of ILI/ARI/SARI using RT-PCR
10- Population Serological Surveillance Collecting blood samples from persons coming for a routine blood
testing
Hospital based types (5 types) Used to identify risk groups for severe disease, clinical spectrum,
measure impact and inform decisions on mitigation measure
11- Hospital-based surveillance for SARI
12- Routine surveillance of nosocomial outbreaks and
outbreaks in long-term care facilities
13- Enhanced surveillance of hospitalized cases
14- Mortality surveillance
15- Health care surveillance
16- Surveillance of wildlife Identification of possible reservoir & human behavioural risk factors
Media, electronic and digital types (4 types) Cost- effective new types depending on using media
17- Help-lines, surveys, participatory surveillance
18- Electronic reporting systems
19- Digital surveillance
20- Event-based surveillance

from Open Sources (EIOS) initiative. It is equally important to mation about the availability and shortages of the key resources
monitor for other potential events that may emerge in parallel, fur- [7,12]. This can slow Covid-19 growth, or even ending the pandemic
ther impacting lives and compromising COVID-19 response efforts. [24]. Incorporation of epidemiologic and virologic surveillance can
Table 2 Summarizes the different types and description of Covid-19 play an important role in the future; once vaccines and antiviral
surveillance. drugs will be available. Such methods can be used to monitor virus
/ vaccine match, and the possible emergence of anti-viral resis-
II- Surveillance indicators and implications in controlling Covid-19 tance [13]. Finally, surveillance among people who have contact
with wildlife, with improvement of biosecurity regarding wildlife
a- Surveillance indicators for monitoring Covid-19: trade, can prevent the next pandemic outbreak [1].
Indicators of transmissibility, seriousness and impact of Covid-
19 are vital. Such indicators can help in informing about the III- Challenges & limitations facing Covid-19 surveillance
measures that need to be taken as social distancing and quarantine
[13,23]. a- Challenges for application of Covid-19 surveillance:
The evaluation of the outcome on hospitals must depend on Public health surveillance in low-resource countries differs from
bed occupancy in wards and ICUs, and the capability for ventila- surveillance in developed nations. There are many challenges for
tion. These indicators can inform decision makers about health-care application of an efficient surveillance in developing countries. The
supply requirements and guide towards shifting or enhancing first one is that more must be done with less. The second challenge
capabilities [13,23]. Further indicators to assess effectiveness of is that strengthening surveillance system in these countries is more
containment measures need to be calculated [28]. The usual complicated due to deficiency of resources and lack of adequate
surveillance indicators as the sensitivity, specificity of surveillance, training. The third one is that sustainability of the surveillance is
timeliness and completeness of the surveillance reports can be also more challenging [30].
calculated [7].
b- Implications of surveillance (How can effective surveillance B- Limitations of Covid-19 surveillance
help in Covid-19 containment)?
Nowadays, efficient surveillance is highly needed for collecting There is major under-ascertainment / under-reporting of total
information, doing action, and hence controlling Covid-19 pan- Covid-19 cases from different countries. There is still uncertainty
demic. Surveillance data gives us pictures of reality, and informs due lack of big longitudinal studies and clinical trial (due to short
policy and decision makers about the situation [24]. It is useful for duration). Covid-19 surveillance is also limited as the mild and sub-
early detection of Covid-19 cases, application of case management clinical cases are usually not seeking treatment. Furthermore, mild
protocol, and containment measures. Such early detection is suc- cases usually avoid hospital unless it is necessary. The testing capac-
cessful for treatment and prevention of further transmission [1]. ity may be also limited for only severe cases. The clinically detected
Exploring and using the open source, web-based tools to modern- cases represent only the tip of ice-berg of the actual infected Covid-
ize mortality data reporting can provide newer, faster insights on 19 cases [12]. Furthermore, the generalized under-detection of the
how to prevent further lives losses [24,27]. imported cases is another limitation. In high-quality surveillance
Surveillance can influence the timeliness of policy applica- locations (based on the Global Health Security index) the over-
tion, public risk perception and decision making [12]. All levels of all ability to detect imported cases is only 40%. In addition, lack
government and healthcare system need detailed and timely infor- of timeliness and completeness of reports are other problems [7].

Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
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Additionally, the quality of surveillance data in many developing time, to make real the potential of the new innovative technology
countries is limited by several factors including resources and train- of tomorrow.
ing [30].
Limitation of the review
Conclusion
There is still a big un-certainty regarding Covid-19, the char-
acteristics of its causative agent (SARS- CoV2) and its surveillance.
Surveillance is one of the cornerstones for controlling Covid-
Furthermore, there is lack of enough data about the types of surveil-
19 pandemic. There are many types of surveillance can be used.
lance used from different countries, especially from the developing
Routine surveillance (comprehensive, case-based and aggregated
countries. As there is very limited number of meta-analysis, sys-
surveillance), active, syndromic, sentinel and sentinel-syndromic
tematic review, clinical trials, follow-up studies about Covid-19
are some types. Laboratory and hospital-based are another types.
surveillance, there is still uncertainty about the evidence.
Help-lines, surveys & participatory surveillance, electronic, digital
surveillance and event-based are other cost-benefit types depend-
ing on media. Surveillance of wildlife was needed in China at The strengths and weaknesses of sources of the article
the start of pandemic and for detection of behavioral risk fac-
tors. All sources were critically appraised. Many articles were from
Surveillance is needed as any missed Covid-19 case can lead WHO, CDC, ECDC & Euro-surveillance. PubMed critically appraised
to new chains of transmission, which may be more difficult for articles were included. Most of the sources are recent. The weakness
containment. is the lack of adequate articles from the developing countries and
Many surveillance indicators can be calculated as transmissi- the level of evidence is still low.
bility, seriousness and the impact of Covid-19. Other important
indicators based on evaluation of the Covid-19 outcome on hos- Appendix A. Supplementary data
pitals. Sensitivity, timeliness and completeness of reports can be
also calculated. Supplementary material related to this article can be found,
There are many challenges facing the application of Covid- in the online version, at doi:https://doi.org/10.1016/j.jiph.2020.07.
19 surveillance. These challenges are mostly related to the 019.
cost, training and sustainability, especially in developing nations.
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Please cite this article in press as: Ibrahim NK. Epidemiologic surveillance for controlling Covid-19 pandemic: types, challenges and
implications. J Infect Public Health (2020), https://doi.org/10.1016/j.jiph.2020.07.019