The Africa Centres for Disease Control and Prevention (Africa CDC) and World Health Organization (WHO) Regional Office for Africa (AFRO) are building a global health security programme that aims to strengthen both regional and national health through networked, collaborative efforts to improve infectious disease and antimicrobial resistance surveillance. To achieve this, the Africa CDC is calling for a data-sharing platform that can be leveraged across member states and disease areas, strengthening the ability to collate, analyse and interpret data, and to respond with the appropriate action.

Although numerous disease intelligence and surveillance systems exist, they are plagued with inaccurate or untimely data. We contend, furthermore, that it was this lack of data quality – and not the lack of surveillance systems or networks – that prevented the global community from acting earlier in response to the Ebola outbreak in 2014–2016. The new field of ‘connected diagnostics’ is one solution to this concern, as it automates data collection directly from the diagnostic instruments to multiple levels of stakeholders for real-time decision-making and policy response.

This article details how the intervention of ‘connected diagnostics’ could solve the primary underlying failure in existing surveillance systems – the lack of accurate and timely data – to enable difficult political decisions earlier. The use of connectivity solutions can enable critical health and operational data to empower the Africa CDC, regional hubs, and each country with a consistent and automated data feed while still maintaining country privacy and controls.

In an interconnected and interdependent world, the threat of any infectious disease is no longer simply a national health concern. Globalisation, despite all of its advantages, has resulted in a world where infectious pathogens can effortlessly traverse borders and threaten global public health security. Outbreaks of infectious diseases are increasing globally with a resurgence of epidemics such as cholera, Ebola and dengue, particularly in Africa. So too, the rise of antimicrobial resistance (AMR) partly due to the increasing use of antibiotics, particularly in low-income countries, poses a worldwide biosecurity and economic threat. The number of deaths globally due to AMR is projected to reach a staggering 10 million per year by 2050.¹

The requirement for timely reporting of infectious diseases has been highlighted on several occasions. A poignant reminder of the impact of poor data quality and timeliness in the management of disease outbreaks is the Ebola outbreak in 2014–2016 – an outbreak that resulted in the loss of $2.2 billion US dollars gross domestic product in Guinea, Sierra Leone and Liberia² as well as 11 325 lives.³ In 2015, an outbreak of a ‘strange disease’ occurred in Kampala, Uganda. The outbreak was thought to have begun in January 2015 or earlier, but was not recognised and reported as a typhoid outbreak until February 2015 due to the lack of surveillance systems; this delay led to thousands being affected and several deaths.⁴ Some countries are reporting an average delay of 22 days from collection of infectious disease specimens to return of results to facilities.⁵ Similarly, in the context of HIV, the return of laboratory result to referring facilities can take up to 90 days⁶ with up to 50% loss of results,⁷ thus, severely delaying initiation of treatment, adherence counselling and switch to second-line treatment.

Monitoring of infectious diseases and AMR through surveillance systems is the cornerstone of any outbreak and response network and the availability of a robust and timely system will ensure a country’s propensity to manage and promptly contain an outbreak.⁸ Time, more than anything, determines the success of a response. However, surveillance systems are largely fragmented and lack input of timely, accurate data.

Africa has been plagued by numerous and recurring epidemics over the past several decades. Not only do these diseases share the ability to decimate entire towns and villages, they also place enormous economic strain on countries.¹³ Global estimates by the World Bank place the annual global cost of a moderately severe to severe pandemic at roughly $570 billion.¹⁴ Responses to many of these diseases have been hampered by weak health care systems, lack of policies that encourage integration and coordination within countries and across borders, and the absence of accurate and timely diagnostic data for decision-making.

When the WHO AFRO attempted to provide an inventory of all epidemics reported in Africa between 1970 and 2016, the effort was impeded by limited data, inconsistencies in reporting of occurrences and magnitudes of outbreaks, and variability in description of outbreak locations.¹⁵

The increasing burden of AMR threatens the effectiveness and success of infectious disease treatment programmes.¹⁶ Africa is thought to contribute a large proportion of the global AMR burden due to limited control and monitoring of use of antibiotics and the high rates of communicable diseases such as HIV and tuberculosis.¹⁷ However, the scarcity of data coming from the region on AMR surveillance reflects the absence of tools to collect valuable information, reliance on passive reporting from centres and lack of training and expertise needed for continuous monitoring and reporting.¹⁶ One review on the status of AMR in Africa found that recent data on AMR was not available for 42.6% of African countries and what was available were lacking in quality, even though resistance to commonly prescribed antibiotics was very high in the African continent.¹⁸ A review of 135 current antibiotic prescribing guidelines also found that, in general, most do not consider resistance patterns for highly prevalent infectious syndromes such as community-acquired pneumonia and urinary tract infections.¹⁹ This largely reflects the lack of collection of accurate resistance data and limits our true understanding of AMR burden.

To ensure an effective response to a potential outbreak event, timeliness is of paramount importance. This requires surveillance, assessment and communication mechanisms to be in place to increase awareness of management strategies, and to facilitate their initiation in the early phases.^21,22 When a passive, paper-based surveillance system was implemented in the public health sector in South Africa for health care-associated infections, the main challenge was incomplete data collection.²³ Nurses felt that manual collection and recording of data added to their workload, thus highlighting the need for systems that are able to automatically collect data and communicate it to various levels of the health care system. Interconnected diagnostic networks can address these needs by facilitating the interactions between laboratory confirmation, automated data collection, interpretation, delivery of results and real-time monitoring of disease as well as analysis. Also, by providing accurate and reliable diagnostic information directly to the point of patient care, more timely patient management and appropriate use of antimicrobials can be facilitated.

Building disease surveillance on connected diagnostics will enable a coordinated response to potential public health threats. In a scenario where a country has diagnostic instruments connected to a system such as GxAlert or Aspect, for example, digital copies of geo-located, disease-positive cases are stored on a country-level database. Each country as well as the Africa CDC RCCs and headquarters could have access to their own operational dashboard based on the permissions set by the Ministry of Health (Figure 1). This type of system would serve the Africa CDC’s need for real-time, geospatial reporting of quality results and enable them to monitor de-identified results of importance, while still preserving the country privacy and controls in place. It would also serve to strengthen the coordinating and supporting role for the RCC in specific sub-regions.

Automated escalations from the national to the RCC level, based on certain thresholds, can initiate effective coordination and allow cross-border surveillance (Table 1). Significant value is obtained from the ability to receive real-time statistics on disease burden, outbreaks, at-risk populations and other epidemiological metrics for further public health threats.

The protection of both patient privacy and national sovereignty are, naturally, strong concerns. The International Health Regulations³¹ provide the legal framework and political agreement needed to help the international community prevent and respond to any potential cross-border threats. However, in practice, creating an effective mechanism for sharing this critical data in a transparent and timely manner has been challenging. The advent of connected diagnostics introduces a new opportunity. The technology is capable of alerting all of the necessary organisations in real-time. The Africa CDC has the mandate and the legal underpinnings within the International Health Regulations to work in concert with nations to negotiate what levels of data access are acceptable and under what conditions (Figure 1). The RCCs do not need to see details that identify an individual patient and might not need to even see specific results, but could be alerted if more than 10 positive Lassa fever results (or plague or Ebola, etc.) occurred within a single month. The alert may simply facilitate a conversation between the RCC and the national emergency operations centre about the cases to see if resources are needed. Although a diagnostic result is not the same thing as a ‘positive patient’, the information is close enough that for pathogens of public health importance, the appearance of an unexpected number of positive results warrants a conversation between the public health bodies involved, at the minimum. The legal framework supporting this has existed for some years. The technology now exists to establish such a surveillance network very affordably; for example, based on the experience of installing and maintaining connectivity services for more than 2100 Cepheid GeneXperts, Abbott m2000s, Becton Dickinson MGITs, Alere PIMAs and Qs, and others by SystemOne, Savics and the Foundation for Innovative New Diagnostics (FIND), the cost to connect the entire continent of Africa’s HIV viral load instruments is only around $5 M per year (or $91 000 per African country). Doing so would provide the systems needed to give every country full, digital access to their HIV viral load testing results at a national, regional, district or site level, the RCC reduced and de-identified access to HIV data in their region, and the Africa CDC the real-time summary information necessary to guide effective policy. Putting the entire continent’s HIV drug resistance testing into a multi-tiered AMR surveillance network is extraordinarily inexpensive and yields extraordinary AMR insights around one of the deadliest diseases in history. The costs for connecting diagnostics for pathogens of concern is, in our opinion, at or below the cost of doing so for HIV. This is attainable in the short term.

As we prepare for future outbreaks and monitoring of AMR, we should use the advanced technologies that are available to us in order to evolve and strengthen key factors in ensuring a well-functioning surveillance strategy: laboratory detection, reporting and response systems. The opportunity exists to take advantage of the ability to collect unprecedented amounts of electronic data from diagnostic platforms through connectivity solutions. By connecting the deployed devices at the beginning of an outbreak or, better yet, prior to new outbreaks during simulations of preparedness, a highly reliable and real-time system for detection and response can be activated at ‘patient zero’. Immediate reports via any electronic means of positive cases can be sent directly to key decision-makers and response coordinators, reducing the time to response, improving data quality issues and stopping unnecessary deaths due to prolonged disease transmission. Reliable, automated data, sent directly from diagnostic systems, enables national, regional, and continent-wide political and health decision-makers to act confidently, as all stakeholders will be utilising high-quality data generated in real-time.