As state governments continue to focus on mitigating further spread of the SARS-CoV-2 coronavirus through stay-in-place orders, building a national COVID-19 surveillance system is crucial for containing transmission of the virus now and preparing for future waves of the infection, according to a new report issued by the Duke-Margolis Center for Health Policy.
“At the same time that we confront the current crisis, we must plan for the future by putting in place tools to enhance our ability to conduct effective surveillance, containment, and case management,” noted the reports’ authors, a team of 5 experts in the health care arena, including 2 former US Food and Drug Administration commissioners, Mark McClellan, MD, PhD, and Scott Gottlieb, MD; and Farzad Mostashari, MD, MSc, former national coordinator for health information technology at the Department of Health and Human Services. “There is no time to lose.”
Case-based interventions—case detection, contact tracing, and isolation—will become an option as incidence of COVID-19 declines, and building capabilities to use such interventions will help the country move beyond the stay-at-home rules and intensive physical distancing measures that became necessary as COVID-19 swept across the United States, they said.
According to the report, A National COVID-19 Surveillance System: Achieving Containment, implementing such a surveillance system will require ongoing coordination by the Centers for Disease Control and Prevention (CDC) and collaboration between the CDC and local and state public health authorities. On state and local levels, every region of the country should aim for key outbreak surveillance and response capabilities: a test-and-trace infrastructure, real-time syndromic surveillance, serologic testing for markers of infection, and rapid response in the form of isolation, contact tracing, and quarantine.
COVID-19 case detection, contact tracing, and isolation are the foundation for minimizing the risk of new outbreaks while easing community restrictions, the report said. This would entail having the capacity to conduct rapid, widespread diagnostic testing for every individual with COVID-19 symptoms as well as for health care workers and others at high risk of contracting or transmitting the virus.
To enable early identification of small outbreaks, an important component of the test-and-trace infrastructure would be a robust regional sentinel surveillance system that would routinely monitor sample populations, particularly vulnerable populations or those in congregate settings. In addition, states and localities must be able to share data electronically, to enable prompt intervention when new cases are detected.
Currently, however, none of the 50 states has sufficient surveillance capabilities to allow case-based interventions at the necessary scale. “With Federal support, surveillance mechanisms can be increased or implemented and better integrated with testing by providers,” the report said.
The authors suggest that a “reasonable first approach” is to support a pilot program in regions that are already working to improve surveillance capabilities. Massachusetts, for example, has a new initiative to hire and train 1000 individuals to improve contact tracing efforts. What can be learned from successful early models and best practices would inform guidance from the CDC to scale up these capabilities throughout the United States.
Another essential component of containing COVID-19 is an enhanced national syndromic surveillance system that integrates COVID-19 test-and-trace data. Syndromic surveillance provides a system for timely detection and monitoring of infectious disease outbreaks and other health events. Tracking symptoms of patients visiting emergency departments, for example, can reveal unusual levels of illness that may provide an early warning for public health concerns, such as influenza outbreaks.
A syndromic surveillance system—including timely access to a range of health-related data across the country, such as electronic feeds of data on hospital admissions, discharges, and transfers—would allow public health officials to monitor spikes and falls in potential COVID-19–related symptoms.
Systems established over the past decade allow for real-time monitoring of a sample of emergency department visits for influenza-like illness and other syndromes of interest. The report noted that in California, New York, and Washington, early experiences with COVID-19 suggest that building on such systems can provide indicators of COVID-19 trends.
This infrastructure for data collection and analysis “should be enhanced to provide additional support for COVID-19 decision making,” the report noted, including prioritizing measures that can provide early signals of community outbreaks.
Also needed is the capacity to conduct widespread serologic testing to identify reliable markers of exposure and immunity. “At the population level, a rigorous large-scale community serosurvey is urgently required to understand the true extent of COVID-19 infections, with important implications for calibrating epidemic models,” the authors said. This would allow an accurate assessment of the fatality rate and the extent to which children are susceptible to infection.
However, they note that questions about the completeness and durability of immunity remain unsettled and will need to be answered before serostatus can be a useful guide for such issues as which individuals may be able to safely return to work.
Currently, the capacity of local public health authorities to respond to the data generated by the surveillance activities is “very limited,” the report said. That means that health systems and public health officials need to scale up capacity to rapidly isolate newly identified COVID-19 cases, conduct contact tracing, and quarantine contacts. “Improved capacity will be most effective if coordinated with health care providers, health systems, and health plans and supported by timely electronic data sharing,” they noted.
To avoid burdening health care facilities and presenting any potential contagion risks, the authors also recommend increasing the capacity to treat new COVID-19 cases effectively at home or in local isolation facilities whenever possible. “The CDC-led collaboration, working with [the Centers for Medicare and Medicaid Services], private payers, and providers, should support the identification of approaches, best practices, and supporting tools to expand effective COVID-19 case management models,” the report noted.
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Joan Stephenson, PhD Joan Stephenson, PhD, is Consulting Editor for the Forum and JAMA and an award-winning independent writer and editor based in Chicago. She joined JAMA as a writer and editor for JAMA's Medical News & Perspectives department and subsequently served...