Epidemic intelligence needs of stakeholders in the Asia–Pacific region

Objective To understand the global outbreak surveillance needs of stakeholders involved in epidemic response in selected countries and areas in the Asia–Pacific region to inform development of an epidemic observatory, Epi-watch. Methods We designed an online, semi-structured stakeholder questionnaire to collect information on global outbreak surveillance sources and limitations from participants who use epidemic intelligence and outbreak alert services in their work in government and nongovernment organizations in the Asia–Pacific region. Results All respondents agreed that it was important to remain up to date with global outbreaks. The main reason cited for following global outbreak news was as an early warning for serious epidemics. Mainstream media and specialist Internet sources such as the World Health Organization (n = 54/91; 59%), the Program for Monitoring Emerging Diseases (ProMED)-mail (n = 45/91; 49%) and the United States Centers for Disease Control and Prevention (n = 31/91; 34%) were the most common sources for global outbreak news; rapid intelligence services such as HealthMap were less common (n = 9/91; 10%). Only 51% (n = 46/91) of respondents thought that their sources of outbreak news were timely and sufficient for their needs. Conclusion For those who work in epidemic response, epidemic intelligence is important and widely used. Stakeholders are less aware of and less frequently use rapid sources such as HealthMap and rely more on validated but less timely traditional sources of disease surveillance. Users identified a need for more timely and reliable epidemic intelligence.

Results: All respondents agreed that it was important to remain up to date with global outbreaks. The main reason cited for following global outbreak news was as an early warning for serious epidemics. Mainstream media and specialist Internet sources such as the World Health Organization (n = 54/91; 59%), the Program for Monitoring Emerging Diseases (ProMED)-mail (n = 45/91; 49%) and the United States Centers for Disease Control and Prevention (n = 31/91; 34%) were the most common sources for global outbreak news; rapid intelligence services such as HealthMap were less common (n = 9/91; 10%). Only 51% (n = 46/91) of respondents thought that their sources of outbreak news were timely and sufficient for their needs.

Conclusion:
For those who work in epidemic response, epidemic intelligence is important and widely used. Stakeholders are less aware of and less frequently use rapid sources such as HealthMap and rely more on validated but less timely traditional sources of disease surveillance. Users identified a need for more timely and reliable epidemic intelligence. E merging and re-emerging diseases are significant threats to global health security. The Asia-Pacific region has been the global epicentre for many emerging infectious diseases, including some with pandemic potential. 1 The emergence of new diseases such as severe acute respiratory syndrome and avian influenza, the threat of diseases external to the region such as Ebola, and recurring outbreaks of endemic diseases highlight the ongoing threat that infectious diseases pose to national, regional and international health security. 1-4 The Asia-Pacific region encompasses two World Health Organization (WHO) regions: South-East Asia and the Western Pacific, home to 3.4 billion people, or over 53% of the world's population. 5 The region is one of the most diverse areas in the world in terms of socioeconomic development, geography and geopolitical influence. 5 It is also particularly vulnerable to emerging and re-emerging infectious diseases due to several factors including increased population growth and movement, urbanization, globalization, limited access to health care, changes in food trade, land degradation and encroachment on natural habitats and antimicrobial resistance. 1,6,7 This rapidly changing landscape, along with weak health systems, limited health infrastructure, resource constraints (financial, human, technical), geographical isolation and poor population health, challenge countries' abilities to adequately prevent, detect and respond to public health threats. [8][9][10][11] The ability to rapidly detect and respond to infectious diseases is critical to global health security. The International Health Regulations, or IHR (2005), provide the legal framework to protect the international community from these threats, requiring Member States to develop core capacities to detect, assess, notify and respond to public health threats and events of national and international concern. 12 WPSAR

METHODS
A semi-structured stakeholder survey was developed and administered electronically using SurveyMonkey (San Mateo, California, USA) between 27 June 2017 and 9 October. The survey questions pertained to respondents' employment characteristics (organization location and type, occupation and position level) and global outbreak surveillance sources (automated outbreak alerts, reasons for following outbreak news services, types of sources and services accessed, limitations of outbreak sources, timeliness and adequacy of outbreak news sources, types of journals accessed at least once a month and preferred format to receive information). Responses to questions consisted of pre-defined single and multiple choice options and a free text "other" option.
The survey was piloted in June 2017 on five individuals with infectious disease experience in government and academic institutions in Australia. Minor changes to the survey were made following feedback to improve the consistency and clarity of questions. Pilot participants were not included in the survey sample or results. The final survey was offered in English, French and Bahasa Indonesia. The survey questionnaire was forward-translated into French and Bahasa Indonesia.
We invited participants to complete the survey from the following countries and areas: Australia; PICTs (American Samoa, Cook Islands, Fiji, French Polynesia, Kiribati, Marshall Islands, New Caledonia, Niue, Commonwealth of the Northern Mariana Islands, Samoa, Tokelau, Tonga, Vanuatu); Indonesia; and Malaysia. Our IHR (2005) emphasize the importance of incorporating event-based surveillance with traditional systems to detect public health risks. 12 Event-based surveillance is "the organized and rapid capture of information about events that are a potential risk to public health". 13 Information can be reported through official or unofficial channels such as media reports, healthcare workers and nongovernment organizations. 14, 15 While traditional indicator-based surveillance systems are essential for collecting and analysing information on known diseases, event-based surveillance systems use broad definitions to detect rare or unusual events and are more timely and sensitive. 13,16,17 They are an essential tool for the rapid detection and assessment of events that could pose serious risks to public health.
Increased availability and reliance on the Internet has driven the development and acceptance of eventbased Internet surveillance as a key tool and source of epidemic intelligence. 17,18 This method brings together disparate sources of data from the Internet to provide a comprehensive overview on the current state of global infectious disease events in near real-time for public health action. 19 There are three types of eventbased Internet surveillance methods for rapid epidemic detection: (1) existing Internet-based surveillance systems and news aggregators that use event-based reporting and syndromic surveillance; (2) search query surveillance using web-based search engines; (3) social media. 20 Understanding countries' needs to detect and respond to infectious disease risks is relevant to common frameworks such as IHR (2005) and the Asia Pacific Strategy for Emerging Diseases that require cost-effective surveillance tools to coordinate health security activities. There are limited studies on the epidemic intelligence needs of end-users. A review of evaluations of 11 global electronic event-based biosurveillance systems found that evaluations focused on the quantitative analysis of system performance. 16 The authors recommended that future evaluations assess the usefulness of systems for public health action for end-users. Stakeholder engagement in all stages of surveillance system development from planning to implementation is important to create a successful and useful system that meets end-users' needs. 16,21 As part of the development of a new epidemic observatory, Epi-watch, we sought to understand the global outbreak surveillance needs of stakeholders Hii et al Epidemic intelligence needs considered part of a single language group, the Malay language) were also grouped together.

Ethics
Ethics approvals were obtained from the following committees: University of New South Wales (

RESULTS
There were 96 responses to the survey and a 96% (92/96) completion rate. Of the 128 surveys emailed to participants, we received a completed response rate of 72% (92/128). Five responses were excluded because respondents did not meet the study inclusion criteria, completed only the first section of the survey or selected a country from which ethics approval was not obtained, leaving 91 (95%) eligible responses.

Survey respondent characteristics
Of the 91 respondents, 55% (50/91) worked in organizations based in Australia, 30% (27/91) in organizations in PICTs and 15% (14/91) worked in Malaysia or Indonesia. Table 1 shows the employment characteristics of survey respondents by region.

Importance of global outbreak news
All 91 respondents agreed that it was important to be up to date with global outbreaks. When asked about sources of automated global outbreak alerts (such as Google alerts or Program for Monitoring Emerging Diseases [ProMED]-mail updates), 60% (55/91) reported receiving automated alerts, 18% (16/91) followed outbreak news sample was targeted to selected countries so that results would be relevant to inform development of an epidemic intelligence system for use within the region. Malaysia and Indonesia were selected in particular because of ongoing, separate research on epidemic surveillance in the Malay and Indonesian languages.
We used several methods to recruit participants. Eligible participants were those who use epidemic intelligence and outbreak alert services in their work across government and nongovernmental organizations. Purposive and snowball sampling methods were used to select individual participants. Representatives of all PICTs were invited to participate through the Pacific Community (SPC). 22 In Australia, participants were identified through the Communicable Diseases Network of Australia, federal and jurisdictional health department websites, an existing list of public health contacts held by the study team, colleagues and organization websites. Malaysian and Indonesian participants were identified through ministries of health. Participants were chosen based on their role and field of employment meeting the study inclusion criteria.
The survey was emailed to 108 participants from Australia, 13 participants from PICTs, four from Malaysia and three from Indonesia. Participants were asked to forward the survey link to relevant colleagues. Three email reminders to complete the survey were sent to countries with a low response rate to meet our overall target sample size of 88.
In addition to emailing eligible participants, a stakeholder workshop was organized by ISER in October 2017 to explore in more depth the outbreak surveillance needs of stakeholders. Workshop attendees were required to complete the survey as a prerequisite for attendance. Eligible attendees at the Communicable Diseases Control Conference in Melbourne, Australia from 27 to 28 June 2017 were also invited to complete the survey.  * The total number of respondents by country/region was used as the denominator to calculate percentages separately by country/region. † Peak body refers to an expert group that provides information, support, advocacy, coordination and strategic guidance to government or nongovernmental organizations. ‡ Senior decision-maker: manages a section/branch/division/head of an organization, has significant and/or final decision-making authority. § Mid-career: manages a small team, has some decision-making authority and/or influence.

Global outbreak news sources
|| Junior: no management role, has limited authority to make decisions. ** Categories were not mutually exclusive as respondents could select more than one option.

Limitations of global outbreak news
Just over half of respondents, 51% (46/91), thought their usual sources of global outbreak news were timely enough for their needs, 20% (18/91) did not find their sources timely and 29% (26/91) were unsure. Fifty-one * Categories were not mutually exclusive as respondents could select more than one option. † Total number of respondents (n = 91) was used as the denominator to calculate percentages to identify the most common reasons for following global outbreak news among all respondents.

Preferred format to receive global outbreak news
Respondents overwhelmingly preferred email as a mechanism to receive global outbreak news. Eightyseven per cent (79/91) of respondents selected this option; 7% (6/91) of respondents preferred websites; 3% (3/91) chose a weekly video presentation; and one each opted for the use of short message service (SMS), social media and other formats. This question did not allow for multiple responses, and feedback from some respondents indicated that they may have had several preferred methods for receiving information, depending on the nature of the outbreak.
A final question asked respondents to provide any other feedback. Answers included needing information for different purposes such as preparation of emergency plans, border health control and advice to traveller consultations; a need to better inform health officials for preparedness, planning and response; and a need for systematized unified surveillance.

DISCUSSION
Our survey provides insight into the epidemic intelligence needs of a diverse range of stakeholders from across the Asia-Pacific region. There was consensus that timely and easily accessible global outbreak notifications are essential to plan for and respond to public health risks. Respondents' professional needs are consistent per cent (46/91) of respondents thought that their usual sources of global outbreak news were sufficient enough for their needs. Twenty-four per cent (22/91) found their sources were insufficient, and an equal proportion were unsure. One respondent (1/91) reported that timeliness and sufficiency were not personally relevant.
The timeliness and sufficiency of outbreak news sources were cross-tabulated by respondent's usual sources of global infectious disease outbreak news ( Table 3). Sixty-two per cent (36/58) of respondents thought that specialist Internet sources such as eventbased Internet surveillance systems were timely enough for their needs, and 55% (32/58) found these sources sufficient ( Table 3).
When asked about the limitations of global outbreak news sources, 42% (38/91) of respondents reported that there was not enough critical appraisal, and 40% (36/91) did not have enough time to read/watch or listen to information. Thirty-two per cent (29/91) of respondents identified that there was not enough information, 30% (27/91) that the sources were not timely enough, and 26% (24/91) that there were too many different sources and did not know which one was best. Twelve per cent (11/91) reported other reasons, such as a delay in or no reporting of events at the country level and lack of local relevance. Nine per cent (8/91) reported no limitations in their sources. Multiple responses were allowed for this question. * Total number of responses for each global outbreak news source was used as the denominator to calculate percentages for timeliness and sufficiency for each source separately, as not all respondents used all sources. † Categories were not mutually exclusive as respondents could select more than one when selecting global outbreak news sources. ‡ One respondent who used these sources reported that timeliness and sufficiency were not relevant to their needs. Hii et al Epidemic intelligence needs Outbreaks 23 and the CDC's Current Outbreak List 37 were more commonly used by respondents over other services such as HealthMap 33 but are less timely. Previous studies have documented significant delays in official reporting of outbreaks compared to unofficial reports. 38, 39 Research has identified that the majority of event-based Internet surveillance systems are generated from North America and Europe; few local systems in the Asia-Pacific region and event-based surveillance systems in general are not well understood in developed and developing countries. 32,36 Increased awareness of the availability and operability of systems providing timely, relevant and reliable information to professionals in the region could address some of these concerns.
Unofficial reports are key sources of information for Internet-based systems, but they can be subject to noise and false alerts, potentially causing unnecessary investigation or alert fatigue among responders. 18 Our findings suggest that reliability and accuracy are important considerations in the choice of global outbreak surveillance sources; however, many respondents were unable to identify the best sources to use. WHO Outbreaks 23 and ProMED-mail 24 were the most commonly accessed sources by many respondents. ProMED-mail is qualitative, but it uses human moderators to review alerts for relevance and accuracy before dissemination, increasing the reliability of reports. 40 A service that can provide critical appraisal, including risk assessment within the broader context of the region, could address the need for more reliable information and help facilitate countries' abilities to assess risks and inform decisionmaking for the response required.
This study had several limitations. Due to the crosssectional online survey design, we were unable to monitor trends in responses/behaviour over time, and findings may not be representative because of the snapshot nature of the timing of the survey and possible non-response bias. As we were interested in stakeholder views at a point in time, this design was appropriate. The online nature of the survey meant that questions could not be explored in-depth; however, a free text option was provided for most questions. Limited access to the Internet and computers in remote and resource-constrained areas could have affected the response rate. Compared to positing surveys, this was the most feasible option, and with some of the most remote PICTs participating, we do not believe access was a major barrier. The study with the key attributes of successful event-based surveillance systems: to be simple, flexible, timely and sensitive. 15 With automated alerts being the predominant information-seeking strategy employed by respondents, Internet-based services that provide this function can support the rapid and timely identification of events to limit the spread and severity of disease outbreaks. 31 A limitation of event-based surveillance systems is that new information is not necessarily disseminated efficiently. 32 While HealthMap 33 is a rapid intelligence source, it was only used by 10% of participants, possibly reflecting low awareness of this resource. Consumers preferred global outbreak alert systems be flexible in the way information is accessed and disseminated. Email was identified by respondents as the preferred communication method to receive global outbreak news; however, these needs may change depending on the context of the outbreak and over time (reflecting generational change in the use of communication technology); systems should consider a range of media such as SMS and social media. Communication technologies such as social media can be harnessed for rapid access and dissemination of information to support emergency preparedness and response. 34 The use of mainstream media and specialist Internet sources for global outbreak news is not surprising given the increased accessibility and reliance on the Internet for information and acceptability of event-based Internet surveillance systems. Approximately 65% of initial reports to WHO about infectious disease events come from informal sources such as the Internet. 35 A 2017 systematic review of event-based Internet biosurveillance systems identified 50 systems, 37 of which were online and fully functioning at the time. 36 Many of these systems use mainstream media as a key source of information. 17, 36 The finding that the same proportion of respondents used both mainstream media and specialist Internet sources for global outbreak news suggests that Internet-based services are not meeting end-users' needs, and other media sources are required to supplement information leading to duplication of effort.
Timeliness of global outbreak news sources was a limitation identified by 51% of survey respondents. One study explored end-users' perceptions of the attributes of seven publicly available event-based Internet surveillance systems and found that timeliness scores ranged from 33% to 100%. 15 Official sources such as WHO Epidemic intelligence needs Hii et al employed purposive sampling instead of probability sampling because of the small and highly specialized pool of eligible participants. While this approach ensured participation of professionals from a wide range of backgrounds and levels who use epidemic intelligence, it can create researcher bias because of the judgmental nature of sample selection. Epidemic response is a small and specialized field, so the sample frame from which we could draw was small, making purposive sampling the most appropriate. Limited inclusion of other large Asian countries, differences in participant selection across countries and low numbers of respondents meant that results could not be compared between countries and may not be generalizable to other countries or representative of the whole Asia-Pacific region. Finally, survey versions in languages other than English were not back-translated, which may have affected the quality of these responses. As 11% (n = 10) of respondents completed the survey in a language other than English, translation inaccuracies are unlikely to have any impact on the overall validity of the survey. Further research on language-specific needs for epidemic surveillance is warranted.

CONCLUSION
For those who work in epidemic response, epidemic intelligence is important and widely used. The choice of sources for global outbreak news varies, and there is less use and awareness of rapid sources such as HealthMap and more reliance on less timely, traditional sources such as WHO and public news media. We identified a need for more timely and reliable epidemic intelligence in the Asia-Pacific region. More effective and efficient sources and methods to deliver user-friendly intelligence to end-users should be explored. There are several global outbreak surveillance systems available; development of a new system should take into consideration how it can integrate into and add value to already established systems within the region.

Conflicts of interest
The authors declare no conflicts of interest.

Funding
This study was funded by the National Health and Medical Research Council Centre for Research Excellence, Integrated Systems for Epidemic Response APP1107393.