Evaluation of the EpiCore outbreak verification system

Bull World Health Organ 2018;96:327–334 | doi: http://dx.doi.org/10.2471/BLT.17.207225 Policy & practice 327 Evaluation of the EpiCore outbreak verification system Taryn Silver Lorthe,a Marjorie P Pollack,a Britta Lassmann,a John S Brownstein,b Emily Cohn,b Nomita Divi,c Dionisio Jose Herrera-Guibert,d Jennifer Olsen,c Mark S Smolinskic & Lawrence C Madoffa Introduction Rapid detection of infectious disease events of potential public health concern allows for control measures to be implemented in a timely manner, thus limiting the size and geographical spread of outbreaks. Traditional disease surveillance is the continuous systematic collection, analysis and evaluation of health information from formal sources. These systems often rely on health-care professionals and diagnostic laboratory data to report information on the illnesses seen in clinical prac- tice, in what is referred to as passive disease surveillance. This information is generally collected, analysed and disseminated by local health authorities, who report to centralized health ministries.1 While the information received is often highly reliable and verified within a uniform structure for reporting, traditional disease surveillance techniques face several chal- lenges. These include: missing information from populations who do not access health care or do so through informal channels; unsuitability to detect new, potentially high-impact outbreaks (such as severe acute respiratory syndrome, avian influenza, Middle East respiratory syndrome); and delays in reporting due to difficulties in obtaining specimens for testing or due to delayed laboratory confirmation. Informal sources or event-based surveillance systems complement formal public health mechanisms in the detection of outbreaks of infectious diseases in humans and animals.2,3 Innovations in disease surveillance can help fill some of the gaps in traditional surveillance by gathering health informa- tion from informal sources, such as social media, word of mouth and local news media, and sharing that information publicly and transparently. The Program for Monitoring Emerging Diseases (ProMED), a programme of the Interna- tional Society for Infectious Diseases, pioneered innovative disease surveillance using the internet and has provided event-based surveillance for emerging infectious diseases since 1994.4,5 The inherent transparency and variety of sources available for event-based surveillance have been credited with speeding up the discovery and public communication of out- breaks.6 However, signals for event-based surveillance, which include media and first-hand reports from astute observers, are often initially unverified by public health authorities or laboratory results. Disease control measures may be delayed while waiting for confirmation.7 As an early warning system, ProMED frequently issues preliminary reports of potential public health events as a request for information in an at- tempt to elicit further verification of these events. However, these requests for information are sent to the entire ProMED membership (> 87 000 subscribers) and our internal data show that they go unanswered up to 95% of the time. In 2013, four global public health organizations ‒ the International Society for Infectious Diseases, the Skoll Global Threats Fund, HealthMap and the Training Programs in Epidemiology and Public Health Interventions Network ‒ formed a partnership to set up the EpiCore global disease surveillance project. Aligning with the World Health Organi- zation’s (WHO) interest in countries developing event-based surveillance systems, EpiCore utilizes crowdsourcing to gather supplementary information to validate rumours and informal reports about disease outbreaks. In this paper we describe the EpiCore disease surveillance project, and analyse data from Objective To describe a crowdsourced disease surveillance project (EpiCore) and evaluate its usefulness in obtaining information regarding potential disease outbreaks. Methods Volunteer human, animal and environmental health professionals from around the world were recruited to EpiCore and trained to provide early verification of health threat alerts in their geographical region via a secure, easy-to-use, online platform. Experts in the area of emerging infectious diseases sent requests for information on unverified health threats to these volunteers, who used local knowledge and expertise to respond to requests. Experts reviewed and summarized the responses and rapidly disseminated important information to the global health community through the existing event-based disease surveillance network, ProMED. Findings From March 2016 to September 2017, 2068 EpiCore volunteers from 142 countries were trained in methods of informal disease surveillance and use of the EpiCore online platform. These volunteers provided 790 individual responses to 759 requests for information addressing unverified health threats in 112 countries; 361 (45%) responses were considered to be useful. Most responses were received within hours of the requests. The responses led to 194 ProMED posts, of which 99 (51%) supported verification of an outbreak, were published on ProMED and sent to over 87 000 subscribers. Conclusion There is widespread willingness among health professionals around the world to voluntarily assist efforts to verify and provide supporting information on unconfirmed health threats in their region. By linking this member network of health experts through a secure online reporting platform, EpiCore enables faster global outbreak detection and reporting. a International Society for Infectious Diseases, 9 Babcock Street, Brookline, Massachusetts, 02446, United States of America (USA). b HealthMap, Harvard Medical School, Boston’s Children’s Hospital, Boston, USA. c Ending Pandemics, San Francisco, USA. d Training Programs in Epidemiology and Public Health Interventions Network, Decateur, USA. Correspondence to Taryn Silver Lorthe (email: taryn.lorthe@isid.org). (Submitted: 15 October 2017 – Revised version received: 18 December 2017 – Accepted: 19 February 2018 – Published online: 16 March 2018 ) Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225328 Policy & practice Outbreak verification system Taryn Silver Lorthe et al. the first 18 months of its implementation to evaluate its usefulness in obtaining information about potential disease outbreaks. Methods Concept EpiCore draws on the local knowledge of a global community of volunteer human, animal and environmental health professionals (called respond- ers) to verify reports from formal and informal sources on disease outbreaks in their own geographical region. They respond to requests for information sent by ProMED moderators (called EpiCore requesters) via a secure online networking and reporting system. The information collected through EpiCore is then shared with ProMED subscribers worldwide, many of whom work in gov- ernment ministries of health and WHO. Implementation Criteria were established for becoming a volunteer EpiCore responder. Re- sponders had to have at least two of the following: an advanced degree in public health or a related field (such as master in public health); health professional certificate or licence (such as doc- tor of medicine, doctor of veterinary medicine, registered nurse); 3–5 years of experience in human or animal health; current affiliation with a medi- cal centre, university, health ministry, department of health or other health- related organization including nongov- ernmental organizations (NGOs) and private sector organizations; or success- ful completion of a field epidemiology training programme. Responders were recruited at Training Programs in Epi- demiology and Public Health Interven- tions Network (TEPHINET) global and regional meetings; at other infectious diseases meetings, such as the Interna- tional Congress on Infectious Diseases (where more than 20% of attendees are in decision-making positions); through targeted recruitment of members of related organizations; and through online recruitment efforts using social media networks and the mailing lists of the partner organizations. The Epi- Core programme manager vetted the applications from responders to ensure they met the above criteria. EpiCore re- sponders were volunteers and obtained no financial compensation for their participation. When EpiCore was implemented, ProMED was using the services of 47 consultants with expertise in the areas of infectious diseases, virology, public health or epidemiology, microbiol- ogy, veterinary medicine, plant biology and toxicology. Located around the world, these ProMED moderators were deployed to continuously collect and analyse formal and informal reports of potential outbreaks in humans, animals and agricultural plants. Formal infor- mation sources included reports and information from health ministries, WHO, academic institutions and NGOs. Informal sources could be articles in the local press or media, reports from individual clinicians or field-based NGO staff, as well as internet-based media such as discussion forums, blogs and social networking sites. When a requester discovered an unverified report of a potential outbreak, he or she used the EpiCore online platform to send a request for information to a selected group of EpiCore responders in a geographical region. Responders received the request in an email and used their on-the-ground knowledge and professional expertise to respond via the online platform. If the requester judged that the information was useful, he or she prepared a ProMED posting using the information provided by the responder and the level of confiden- tiality requested. This was posted to the ProMED website (http://www. promedmail.org) and sent in an email to ProMED’s more than 87 000 subscribers from 195 countries. EpiCore was listed as the source of information in ProMED reports unless the responder preferred to be more specifically identified. A digital platform was developed by HealthMap (Boston Children’s Hospital, Boston, United States of America) with input from the International Society for Infectious Diseases and other part- ners, to allow secure communication between requesters and responders. When making a request for informa- tion the requester was able to select EpiCore responders by country or by using a bounding box on the online platform that showed the approximate location of potential responders as pins on a map. To maintain confidentiality, responders were identified in the plat- form by a unique responder identifica- tion number. The requester was not able to identify the responders unless the responders chose to include their name and information when responding to a request for information. Responders had three choices about how their response would be used in a subsequent ProMED post: (i) paraphrase or do not use direct quotes from this response, mask any identifying information referenced in the response text and do not provide any details on my identity; (ii) quote this response, but mask identifying information referenced in the response text and do not provide any details on my identity; (iii) quote this response and attribute it to me. Secure shell protocol was used to authenticate and establish a secure connection between the participating EpiCore responder and project servers. Secure shell protocol is a commonly used encrypted network protocol to allow secure connections over unse- cure networks such as the internet. The EpiCore data transferred to the EpiCore cloud server, which was then stored in the EpiCore database (MySQL) on an Amazon web services relational database service. The database was ac- cessed only from the elastic compute cloud server over a transmission control protocol connection using MySQL, port 3306. The secure connection required a password, known only by project devel- opers, to connect to the database. Responders received training about innovative disease surveillance methods (the use of informal or unstructured data such as media reports and ru- mours), techniques for validation of information and the use of the online digital platform for responses. The train- ing took about one hour and prospec- tive EpiCore members could complete the course online or in-person at ISID conferences or TEPHINET workshops. Trainings were also held for requesters, both in-person and online, about how to generate requests for information, use the digital platform to receive re- sponses, safeguard the confidentiality of responses and disseminate responses that either validated or de-escalated unverified outbreaks. Project evaluation We used data from the EpiCore platform database since its inception through to September 2017 and analysed it using Excel (Microsoft Office 2011, Micro- soft Corp., Redmond, USA). These data included information on both the EpiCore responders and the requests for information that had been initiated. Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225 329 Policy & practice Outbreak verification systemTaryn Silver Lorthe et al. Demographic information on EpiCore responders included geographical location, education level, professional background, years of experience and work sector. Data on the requests for information included the geographical location where the requests were sent, number of members reached, number of responses received, rating of usefulness of member responses and time from request for information initiation to first response. Requesters graded responses as useful if they contributed information supporting, providing additional data or refuting an event. Each response that led to a ProMED report was evaluated by two of the authors to determine whether a report supported verification (indi- cated laboratory or other confirmatory data supporting the diagnosis), refuted verification (negative laboratory data or finding of an alternative diagnosis) or provided additional information (such as serotype or information on extent of an outbreak). Some EpiCore reports provided no new information and were categorized as such. Duplicate reports, such as those from ProMED regional networks, were combined and consid- ered as a single report. Results Between March 2016 and September 2017, 2068 human, animal and envi- ronmental health professionals from 142 countries applied and trained in informal disease surveillance and the use of the EpiCore platform. The major- ity of EpiCore responders self-identified as having a professional background in human health (1039, 54%), followed by human and environmental health (329, 17%), animal health (215, 11%), human and animal health (142, 7%), human and animal and environmental health (127, 7%), environmental health (40, 2%) and animal and environmental health (35, 2%). About half of current EpiCore responders (1073, 52%) had more than 10 years of experience in their respective field of work. Another 530 (26%) had 5–10 years of experience, 298 (14%) had 3–5 years of experience and 167 (8%) had less than 3 years of experience. Most EpiCore responders (1259, 61%) worked in the government sector, 488 (24%) in NGOs or the non-profit sector and 320 (15%) in the private sector. From March 2016 to September 2017, requesters sent 759 requests for information concerning unverified outbreak alerts to EpiCore responders. Requests for information addressed events in over 100 countries (Fig. 1), had 15 120 views by a member and elicited 1923 responder responses. Of the requests for information, 466 (61%) received at least one response (Table 1). The time from issuing the request to receiving the first response ranged from 1 minute to 62 days with a median of 6 hours. Of the 790 individual responses, 361 (45%) were considered to be useful by the requester and led to a ProMED post to subscribers. Examples of useful responses to requests for information received via EpiCore are shown in Box 1. EpiCore responses informed 194 ProMED posts to subscribers: 99 (51%) supported verification, 56 (29%) provided additional information, 23 (12%) refuted verification and 16 (8%) provided no new information. Discussion Innovative disease surveillance meth- ods are already being used to speed up the detection of public health threats, some of which have global importance. ProMED, HealthMap and other systems that rapidly detect outbreaks digitally through unofficial information sources are widely used by those in charge of responding to outbreaks.13 However, unofficial data may consist of unveri- fied information (sometimes referred to as rumours), and actions to control outbreaks may be delayed pending fur- ther verification. In many cases, initial reports of potential public health events are found in media reports that do not mention confirmation from government sources. EpiCore complements current ministry of health and WHO systems by addressing these gaps and verifying or refuting numerous unconfirmed public health events. In many other cases, Epi- Core responders were able to provide supplementary data that could assist in formulating outbreak response efforts. Analysis of nearly 200 ProMED reports during the study period citing EpiCore data indicated that, in most cases, the report was validated. In other cases, alternative explanations for events or negative test results were found or additional data concerning the event were provided and posted to ProMED subscribers. The purpose of epidemic intelligence is to allow timelier public health action towards containment, disease control and other measures that may reduce the size and geographical spread of an outbreak. EpiCore has shown the ability to improve the veri- fication (or refutation) of unconfirmed outbreaks and to identify the etiology of unknown outbreaks. While such ad- ditional information may not provide absolute verification, we believe that at times it will be sufficient to allow public actions to mitigate potentially danger- ous situations. The finding that 759 requests for information were generated (more than one per day during the study period), and that 61% of these received at least one response deemed useful by the re- quester, indicates the potential value of EpiCore in validating outbreak reports. More than half of the responses vali- dated the request for information, sup- porting the usefulness of event-based surveillance. While we were not able to determine the actions taken as a result of these reports, we hope to be able to collect this information in the future. However, actions undertaken as a result of such reports could reduce the size, geographical extent, morbidity, mortal- ity and economic costs of outbreaks. Ad- ditional information obtained through EpiCore reports (such as serotypes or antimicrobial resistance of disease- causing organisms) could improve the quality of outbreak responses. Refuta- tion of reports could reduce unnecessary actions and thus reduce costs to public health agencies. Current challenges and limitations of EpiCore include the uneven geo- graphical distribution of responders, with some countries and regions over- represented and others, including some hotspots for emerging diseases, under- represented. Some countries have no or very few responders. This is due in part to recruitment efforts being driven by the location of infectious disease confer- ences, ProMED subscribers and partner organizations. Not all requests for infor- mation received helpful responses and some requests for information generated more responses than could be easily used. Responses to requests for informa- tion are evaluated on their usefulness by the requester, which is subjective. A high level of expertise is required by the requester to properly frame the queries included in requests for information and to interpret responses meaningfully. Some responders, despite the promise of anonymity, expressed misgivings about providing responses when this con- Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225330 Policy & practice Outbreak verification system Taryn Silver Lorthe et al. Fi g. 1 . Lo ca tio ns o f 2 06 8 re sp on de rs in 1 42 co un tr ie s i n th e Ep iC or e di se as e su rv ei lla nc e pr oj ec t, No ve m be r 2 01 5 to Se pt em be r 2 01 7 Re sp on de r’s lo ca tio n 0 80 00 60 00 40 00 20 00 10 00 0 km N D at a So ur ce : E pi Co re D ise as e Su rv ei lla nc e Pr oj ec t. Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225 331 Policy & practice Outbreak verification systemTaryn Silver Lorthe et al. Ta bl e 1. Di st rib ut io n by co un tr y o f r es po nd er s, re qu es ts fo r i nf or m at io n an d re sp on se s in th e Ep iC or e di se as e su rv ei lla nc e pr oj ec t, No ve m be r 2 01 5 to Se pt em be r 2 01 7 Co un tr y No . o f re qu es ts fo r in fo rm at io n se nt To ta l n o. of Ep iC or e re sp on de rs in co un tr y No . o f re sp on se s t o re qu es ts fo r in fo rm at io n No . ( % ) o f re qu es ts fo r in fo rm at io n w ith a t l ea st on e re sp on se No . ( % ) of u se fu la re sp on se s In di a 12 1 18 6 91 60 (5 0) 72 (7 9) U ni te d St at es 78 39 9 38 51 (6 5) 37 (9 7) Pa ki st an 51 86 97 37 (7 3) 70 (7 2) Ira q 43 20 29 22 (5 1) 24 (8 3) Eg yp t 30 18 18 17 (5 7) 17 (9 4) Sa ud i A ra bi a 30 12 9 13 (4 3) 6 (6 7) Sy ria n Ar ab Re pu bl ic 30 0b 0 19 (6 3) 0 (0 ) N ig er ia 19 18 9 17 6 19 (1 00 ) 17 1 (9 7) Ba ng la de sh 16 33 11 8 (5 0) 10 (9 1) Br az il 14 32 21 11 (7 9) 11 (5 2) An go la 12 3 0 0 (0 ) 0 (0 ) N ep al 12 25 21 6 (5 0) 17 (8 1) Isr ae l 11 7 9 7 (6 4) 7 (7 8) So ut h Af ric a 10 19 8 7 (7 0) 8 (1 00 ) U ni te d Ki ng do m 10 61 15 9 (9 0) 11 (7 3) Ru ss ia n Fe de ra tio n 9 7 4 5 (5 6) 3 (7 5) Ka za kh st an 8 1 0 2 (2 5) 0 (0 ) Ke ny a 8 25 8 6 (7 5) 5 (6 3) M ya nm ar 8 4 3 2 (2 5) 3 (1 00 ) Ph ili pp in es 8 77 10 8 (1 00 ) 10 (1 00 ) Al l o th er co un tri es 23 1 71 9 79 0 15 7 (6 8) 18 7 (9 3) To ta l 75 9 19 23 c 13 58 46 6 (6 1) 66 9 (8 7) a Us ef ul re sp on se s a re id en tifi ed b y th e re qu es te r w he n a re sp on se c on tri bu te s i nf or m at io n su pp or tin g, pr ov id in g ad di tio na l d at a or re fu tin g an e ve nt . b Re qu es ts fo r i nf or m at io n m ay b e se nt to re sp on de nt s i n ne ig hb ou rin g co un tri es if th er e ar e no m em be rs in th e co un tr y w he re th e ev en t i s o cc ur rin g. c Th e to ta l n um be r o f E pi Co re re sp on de rs in th is ta bl e in cl ud es o nl y th os e m em be rs in c ou nt rie s w he re a re qu es t f or in fo rm at io n w as se nt . T hi s t ab le li st s t he 2 0 co un tri es w ith th e m os t r eq ue st s f or in fo rm at io n re ce iv ed . Bo x 1. Ex am pl es o f u se fu l r es po ns es to re qu es ts fo r i nf or m at io n re ce iv ed b y t he Ep iC or e di se as e su rv ei lla nc e pr oj ec t, No ve m be r 2 01 5 to Se pt em be r 2 01 7 • A re po rt o n a po lio ca se in G ilg it- Ba lti st an , P ak ist an , w as re ce iv ed b y P ro M ED , w hi ch w as th e fir st c as e re po rt ed fr om th at a re a sin ce 2 01 1. A re qu es t f or in fo rm at io n w as se nt to E pi Co re re sp on de rs to id en tif y w he th er th e po lio vi ru s in vo lv ed in th is ca se w as a w ild p ol io vi ru s or v ac ci ne d er iv ed . W ith in o ne h ou r, a re sp on de r c on fir m ed th e ca se w as d ue to a w ild po lio vi ru s w ith g en et ic li nk ag es to a v iru s id en tifi ed in e nv iro nm en ta l s am pl es in L ah or e fro m th e pr ev io us y ea r.8 ,9 • Pr oM ED re ce iv ed a re po rt fr om a m ed ia so ur ce ab ou t a lo ca liz ed p ot en tia l in fe ct io us d ise as e ou tb re ak a nd a re qu es t f or in fo rm at io n w as s en t t o ov er 1 00 n ea rb y Ep iC or e re sp on de rs . Th e re qu es t f or in fo rm at io n re ce iv ed e ig ht re sp on se s t ha t n ot o nl y c on fir m ed th e ou tb re ak , bu t a lso a le rt ed a lo ca l g ov er nm en t o ffi ci al w ho h ad y et to h ea r a bo ut th e ou tb re ak a nd re po rt ed th at a te am h ad b ee n se nt to in ve st ig at e. 10 (T he c ou nt ry a nd d ise as e in fo rm at io n ha s b ee n om itt ed to m ai nt ai n re qu es te d co nfi de nt ia lit y of th e Ep iC or e re sp on de rs ). • Af te r r ec ei vi ng a re po rt fr om a m ed ia so ur ce ab ou t c ho le ra in Z am bi a, P ro M ED se nt a re qu es t fo r i nf or m at io n to E pi Co re re sp on de rs a sk in g fo r m or e in fo rm at io n an d up da te d nu m be rs . W ith in 1 0 m in ut es , a n Ep iC or e re sp on de r c on fir m ed 1 1 ca se s an d th e fo llo w in g da y th is nu m be r w as c on fir m ed b y an ot he r E pi Co re re sp on de r.1 1 • Pr oM ED re ce iv ed a re po rt o f s us pe ct ed C rim ea n– Co ng o ha em or rh ag ic fe ve r i n Pa ki st an . A re qu es t f or in fo rm at io n w as se nt to E pi Co re re sp on de rs in P ak ist an a nd w ith in le ss th an a n ho ur a re sp on de r r ep lie d re fu tin g th e di ag no sis .12 Pr oM ED : P ro gr am fo r M on ito rin g Em er gi ng D ise as es o f t he In te rn at io na l S oc ie ty fo r I nf ec tio us D ise as es . Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225332 Policy & practice Outbreak verification system Taryn Silver Lorthe et al. صخلم ضارملأا شيفت نع فشكلل روكبيإ ماظن مييقت فوقولاو )روكبيإ( يعمالجا ضرلما ةبقارم عوشرم فصو ضرغلا ةلمتحلما ثداولحاب ةقلعتلما تامولعلما عيمتج في هتيهمأ ىدم لىع .ضارملأا راشتنلا ناسنلإا ةحص في ينصصختلما نم نوعوطتم مضنا ةقيرطلا اوعضخو روكبيإ عوشرم في لماعلا ءاحنأ عيجم نم ةئيبلاو ناويلحاو ددته يتلا رطاخلماب ةقلعتلما تاراذنلإا نع ركبلما فشكلل بيردتلل مادختسلاا ةلهس ةنمآ ةحصنم برع ةيفارغلجا مهتقطنم في ةحصلا ةئشانلا ةيدعلما ضارملأا لامج في ءابرلخا لسريو .تنترنلإا برع يرغ ةيحصلا رطاخلما نأشب تامولعم لىع لوصحلل تابلط ةفرعلماو ةبرلخاب مهرودب اوناعتسا نيذلاو ،ينعوطتلما لىإ ةتبثلما دودرلا كلت ةعجارمب ءابرلخا ماقو .تابلطلا هذه لىع درلل ةيلحلما عمتجلما طاسوأ في اًعيسر ةمالها تامولعلما شرنو اهصيخلتو ةدمتعلما ضارملأا ةبقارلم ةيلالحا ةكبشلا قيرط نع يلماعلا يحصلا .ProMED مساب ةفورعلماو ،عئاقولا لىع لوليأ/برمتبس 10 ىتح 2016 راذآ/سرام نم ةترفلا في جئاتنلا ةلود 142 نم روكبيلإ اًعبات اًعوطتم 2068 عضخ ،2017 مادختساو يمسر يرغ ٍلكشب ضارملأا ةبقارم قرط لىع بيردتلل اًيدرف اًدر 790 نوعوطتلما مدقو .تنترنلإا لىع روكبيإ ةصنم يرغ ةيحصلا رطاخلماب قلعتي مايف تامولعملل اًبلط 759 لىع نمض )% 45 ةبسنب( اًدر 361 رابتعا متو ؛ةلود 112 في ةتبثلما نم تاعاس للاخ دودرلا بلغأ ملاتسا متو .ةديفلما دودرلا ـل اًعبات اًروشنم 194 شرن دودرلا كلت نع جتنو .تابلطلا لاسرإ ،ضرلما شيفت لىع ًلايلد اهنم )51% ( 99 مدق ثيح ،ProMED .كترشم فلأ 87 نم رثكأ لىإ الهاسرإو ProMED لىع اهشرن متو ينيحصلا ينيئاصخلأا ينب قاطنلا عساو دادعتسا كانه جاتنتسلاا فشكلل اًعوط ةلوذبلما دوهلجا في تادعاسم ميدقتل لماعلا لوح .مهتقطنم في ةديكأ يرغ ةيحص رطامخ دوجو تبثت تامولعم ميدقتو للاخ ةحصلا ءابرخ نم ةنوكلما ءاضعلأا ةكبشب لاصتلاا لضفبو فشكلا ينكتم لىع روكبيإ لمعت ،تنترنلإا لىع ةنمآ غلابإ ةصنم .اهنع غلابلإاو اًيلماع ضارملأا شيفت نع عيسرلا flicted with the confidentiality require- ments of their other professional duties. Neither ProMED nor EpiCore respond directly to public health outbreaks and emergencies. The goal is to provide ac- tionable information, but it is too early in the project to identify specific actions taken as a result of EpiCore responses. In the future, we will tabulate public health responses to events, although any action taken cannot necessarily be attributed to EpiCore since public health authorities could be acting on information received elsewhere. During the project period, EpiCore was able to demonstrate the value of crowdsourcing for enhancing disease surveillance activities by showing the feasibility of recruiting and training highly qualified volunteer professionals around the world for outbreak valida- tion and verification. A secure digital platform was developed that facilitated swift interaction between information requesters and EpiCore responders in targeted geographical areas, while safe- guarding the confidentiality of EpiCore responders. Requesters could then rapidly and transparently disseminate additional information supporting or refuting the veracity of outbreaks through ProMED so that appropriate public health action could occur. EpiCore does not aim to replace any official reporting system and cannot be considered verification in WHO terms as that would require confirmation by a member state’s public health authority, usually based on laboratory evidence. EpiCore is meant to be a complemen- tary tool supporting traditional and official surveillance systems through crowdsourcing. As ProMED subscrib- ers include many personnel from the WHO, World Organisation for Animal Health, national ministries of health and agriculture and many regional and local health authorities, the information EpiCore obtains reaches those subscrib- ers. In many cases, the initial reports of events of potential interest to the health sector (both human and animal) are found in media reports that do not include confirmation from government sources. In those cases, the reports gen- erated by responses may assist WHO and national governments in their own verification processes. EpiCore software version 2.0 is now being developed and will attempt to address some of the limitations of the current system. The software will include enhancements to the user experience for both requesters and responders that we expect will lead to improved response rates and quality. We plan to provide greater engagement with responders through more frequent communication, additional requester groups and non- monetary incentives. Finally, we plan to recruit responders from regions not currently adequately represented and to include subject-matter expert respond- ers who can help provide information on potential outbreaks regardless of geographical location. Results from this initial period will provide baseline rates against which future responses can be assessed. Ultimately, we believe this will contribute to faster outbreak detec- tion and quicker responses, limiting the extent of outbreaks and preventing pandemics.14 ■ Acknowledgements We thank Maja Carrion for reviewing the manuscript and Evan Caten for as- sistance with the mapping. Funding: Grant funding was provided by Skoll Global Threats Fund, now known as Ending Pandemics, to the International Society for Infectious Diseases, Health- Map and the Training Programs in Epide- miology and Public Health Interventions Network for the initial phases of EpiCore. The final costs of the project are not yet determined. Costs will depend on the size and scope of the system, including the numbers of requesters and responders. Competing Interests: None declared. Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225 333 Policy & practice Outbreak verification systemTaryn Silver Lorthe et al. 摘要 EpiCore 疾病突发证实系统的评估 目的 旨在描述众包疾病监测项目 (EpiCore) 并评估其在 获取潜在疾病突发信息方面的有用性。 方法 从世界各地招募人类、动物和环境卫生方面的专 业人员志愿者至 EpiCore，并且通过安全、易于使用的 在线平台让志愿者在其所处的地理区域接受培训，从 而提供公共卫生威胁警报的早期证实。新兴传染病领 域的专家向这些志愿者发出针对尚未证实卫生威胁的 信息请求，这些志愿者得以运用其对当地情况的了解 和专业知识，对相应请求做出回应。专家对这些回应 进行审查和归纳，同时通过现有基于事件的疾病监测 网络——ProMED，将重要信息迅速传播至全球卫生社 区。 结果 2016 年 3 月至 2017 年 9 月，来自 142 个国家 的 2068 名 EpiCore 志愿者接受了非正式疾病监测以及 EpiCore 在线平台使用的培训。这些志愿者针对 759 份 关于解决 112 个国家尚未证实卫生威胁的信息请求， 提供了 790 份个人回答，其中 361 (45%) 份回答显示 为有用。大多数回应能够在信息请求发出后数小时 之内收到。这些回应生成了 194 份 ProMED 帖子，其 中 99 (51%) 份为疾病突发的证实提供了支持。这些帖 子被发布在 ProMED 上并被发给 87000 多名订阅者。 结论 在全世界的卫生专业人员中，很多人愿意主动协 助，提供其所在地区尚未确定卫生威胁的证实情况和 支持信息。通过一个安全的在线报告平台连接卫生专 家成员网络，EpiCore 加快了全球疾病突发的监测与报 告。 Résumé Évaluation du système de vérification des épidémies EpiCore Objectif Décrire un projet participatif de surveillance des maladies (EpiCore) et évaluer son utilité pour obtenir des informations sur d’éventuelles flambées épidémiques. Méthodes Des professionnels bénévoles de la santé humaine, animale et environnementale du monde entier ont été recrutés dans le cadre du système EpiCore. Ces professionnels ont été formés pour effectuer une vérification rapide des alertes sanitaires dans leur région géographique par l’intermédiaire d’une plate-forme en ligne sécurisée et facile à utiliser. Des experts des maladies infectieuses émergentes ont envoyé des demandes d’informations sur des menaces sanitaires non vérifiées à ces bénévoles, qui ont utilisé les connaissances et l’expertise disponibles localement pour y répondre. Les experts ont examiné et synthétisé les réponses fournies, puis ont rapidement diffusé les informations importantes à la communauté sanitaire mondiale par le biais de ProMED, un réseau de surveillance des maladies fondée sur des faits. Résultats Entre mars 2016 et septembre 2017, 2068 bénévoles EpiCore originaires de 142 pays différents ont été formés aux méthodes de surveillance informelle des maladies et à l’utilisation de la plate-forme en ligne EpiCore. Ces bénévoles ont fourni 790 réponses individuelles aux 759 demandes d’informations portant sur des menaces sanitaires non vérifiées dans 112 pays; 361 (45%) réponses ont été jugées utiles. La plupart des réponses ont été reçues quelques heures après la demande. Les réponses ont donné lieu à 194 articles ProMED, dont 99 (51%) soutenaient la vérification d’une épidémie et ont été publiés sur ProMED et envoyés à plus de 87 000 abonnés. Conclusion De nombreux professionnels de santé du monde entier sont prêts à soutenir bénévolement les efforts visant à vérifier les menaces sanitaires non confirmées dans leur région et à fournir des informations complémentaires à leur égard. En reliant les membres de ce réseau d’experts de la santé par l’intermédiaire d’une plate-forme en ligne sécurisée, EpiCore permet d’accélérer la détection des épidémies mondiales et l’établissement de rapports. Резюме Оценка системы проверки информации о вспышках заболеваний EpiCore Цель Описать проек т для наблюдения и контроля заболеваний (EpiCore), организованный по принципу краудсорсинга, и оценить его практическую ценность в получении информации о потенциальных вспышках заболеваний. Методы Компанией EpiCore со всего мира были на добровольных началах набраны специалисты по охране здоровья человека, животных и окружающей среды, которые прошли подготовку по обеспечению ранних проверок предупреждений об угрозах для здоровья в своем географическом регионе с помощью безопасной и простой в использовании онлайн-платформы. Эксперты в области возникающих инфекционных заболеваний направили запросы на получение информации о непроверенных угрозах здоровью этим добровольцам, которые использовали местные знания и опыт для ответа на запросы. Эксперты рассмотрели и обобщили ответы и быстро распространили важную информацию среди мирового сообщества специалистов здравоохранения с помощью существующей, основанной на событиях сети мониторинга заболеваний ProMED. Результаты С марта 2016 года по сентябрь 2017 года 2068 добровольцев компании EpiCore из 142 стран прошли обучение методам неофициального наблюдения и контроля заболеваний и использованию онлайн-платформы EpiCore. Эти добровольцы предоставили 790 индивидуальных ответов на 759 запросов на получение информации, касающейся непроверенных угроз здоровью в 112 странах; 361 ответ (45%) был признан полезным. Большинство ответов было получено в течение нескольких часов после поступления запроса. Ответы послужили основой для публикации в ProMED 194 сообщений, отправленных более чем 87 000 подписчиков, в 99 из этих сообщений (51%) была предоставлена подтверждающая информация о вспышках заболеваний. Вывод Специалисты в области здравоохранения во всем мире проявляют готовность добровольно содействовать усилиям по проверке и предоставлению вспомогательной информации о неподтвержденных угрозах для здоровья в их регионе. Используя эту сеть экспертов в области здравоохранения с помощью безопасной онлайн-платформы для сообщения данных, EpiCore обеспечивает более быстрое глобальное обнаружение вспышек заболеваний и составление отчетности. Bull World Health Organ 2018;96:327–334| doi: http://dx.doi.org/10.2471/BLT.17.207225334 Policy & practice Outbreak verification system Taryn Silver Lorthe et al. Resumen Evaluación del sistema de verificación de brotes de EpiCore Objetivo Describir un proyecto de control de enfermedades con participación pública (EpiCore) y evaluar su utilidad para obtener información sobre potenciales brotes de enfermedad. Métodos Se reunieron a profesionales de salud humana, animal y medioambiental de todo el mundo para el proyecto EpiCore y se capacitaron para proporcionar verificación temprana de alertas de amenazas para la salud en su región geográfica a través de una plataforma segura, fácil de usar y en línea. Los expertos en el área de enfermedades infecciosas emergentes enviaron solicitudes de información sobre amenazas para la salud no verificadas a estos voluntarios, quienes utilizaron el conocimiento local y la experiencia para responder a las solicitudes. Los expertos revisaron y resumieron las respuestas y rápidamente distribuyeron información importante a la comunidad mundial de salud a través de la red de control de enfermedades basada en eventos existentes, ProMED. Resultados Desde marzo de 2016 hasta septiembre de 2017, 2068 voluntarios de EpiCore de 142 países se formaron en métodos de control de enfermedades casuales y el uso de la plataforma en línea de EpiCore. Estos voluntarios proporcionaron 790 respuestas individuales a 759 solicitudes de información sobre amenazas para la salud no verificadas en 112 países; de estas respuestas, 361 (45%) se consideraron útiles. La mayoría de las respuestas se recibieron en cuestión de horas a partir de la solicitud. Las respuestas condujeron a 194 artículos de ProMED, de los cuales 99 (51%) respaldaron la verificación de un brote, se publicaron en ProMED y se enviaron a más de 87 000 suscriptores. 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