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\begin{document}

\title{Facing the future of respiratory virus surveillance: ``The mosaic
surveillance framework''}



\author[1]{Joshua Mott}%
\author[1]{Isabel Bergeri}%
\author[1]{Hannah Lewis}%
\author[2]{Anthony Mounts}%
\author[1]{Sylvie Briand}%
\affil[1]{World Health Organization}%
\affil[2]{The Task Force for Global Health}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
It is impossible to address the many complex needs of respiratory virus
surveillance with a single system. Therefore, multiple surveillance
systems and complementary studies must fit together as tiles in a
``mosaic'' to provide a complete picture of the risk, transmission,
severity, and impact of respiratory viruses of epidemic and pandemic
potential. Below we present a framework to assist national authorities
to identify priority respiratory virus surveillance objectives and the
best approaches to meet them; to develop implementation plans according
to national context and resources; and to prioritize and target
technical assistance and financial investments to meet most pressing
needs.%
\end{abstract}%



\sloppy


\textbf{Facing the future of respiratory virus surveillance:}

\textbf{``The mosaic surveillance framework''}

\textbf{Joshua A. Mott, Isabel Bergeri, Hannah C. Lewis, Anthony W.
Mounts, and Sylvie C. Briand}

\textbf{Abstract: (100/100 words)}

It is impossible to address the many complex needs of respiratory virus
surveillance with a single system. Therefore, multiple surveillance
systems and complementary studies must fit together as tiles in a
``mosaic'' to provide a complete picture of the risk, transmission,
severity, and impact of respiratory viruses of epidemic and pandemic
potential. Below we present a framework to assist national authorities
to identify priority respiratory virus surveillance objectives and the
best approaches to meet them; to develop implementation plans according
to national context and resources; and to prioritize and target
technical assistance and financial investments to meet most pressing
needs.

\textbf{Short Communication (1354/1500 words):}

\emph{The need for the mosaic framework}

As we progress through the coronavirus disease 2019 (COVID-19) pandemic
towards an inter-pandemic period, countries are faced with the need to
sustainably transition their surveillance strategies to monitor
influenza, SARS-CoV-2, Respiratory Syncytial Virus (RSV) and other
respiratory viruses of epidemic and pandemic potential. Population
expansion, travel patterns, and global trade also present an ongoing
risk of new pandemics, and a continuing need to strengthen early warning
surveillance. To face these challenges countries must now increase the
number of effective surveillance approaches to address multiple
surveillance objectives, and extend partnerships for surveillance and
collaborative analyses of data across sectors. Doing so will improve
data for decision-making during interpandemic periods and to help ensure
that respiratory virus surveillance is both timely and scalable in
emergencies.

WHO Member States have requested a coordinated approach to the
sustainable monitoring of respiratory viruses of epidemic and pandemic
potential (1). For respiratory virus surveillance to function during
interpandemic periods, and to be resilient to inform decision-making
during times of emergency, surveillance systems must be well-suited to
the objectives that they are being implemented to address.
Fit-for-purpose surveillance will produce actionable and policy-relevant
information that will engender trust and demonstrate their value for
money, increasing commitment by public health authorities to invest in
surveillance over time. Conversely, poorly targeted, or inefficient
surveillance systems may generate sub-optimal or misleading data for
decision-making, and not be perceived as cost-effective to sustain or
scale in emergencies. Comprehensive surveillance for respiratory viruses
involves detecting and assessing emerging or re-emerging pathogens;
monitoring epidemiological and clinical characteristics of illness
associated with infections and the virological characteristics of
respiratory viruses currently in circulation; and informing the use of
human health interventions (Figure 1). As it is impossible to address
all these objectives with a single surveillance system, multiple systems
and complementary investigations (2) must work together to address the
many information needs of policy makers. In essence, each system or
study serves as a tile in a ``mosaic'', and only when viewed together
will they provide the complete and understandable picture of the human
health risk and impact associated with epidemic and pandemic respiratory
viruses in circulation.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1: Surveillance domains and associated objectives for
respiratory viruses of epidemic and pandemic potential}

The COVID-19 pandemic generated innovations to support surveillance,
including those related to improved point of care or self-test
diagnostic technologies, environmental surveillance, community
participatory surveillance, and the rapid improvement in global genomic
surveillance \emph{(3)} . To inform longer-term surveillance planning,
this framework considers some of the benefits, limitations, and most
appropriate applications of these innovations to inform possible
surveillance strategies.

Critically, national surveillance strategies must be directed by the
objectives and information needs of local authorities, locally available
resources, and feasibility within the populations under surveillance.
Surveillance methods that can help address needed objectives include but
are not limited to event-based surveillance in health care facilities,
the community and at the animal-human interface; sentinel surveillance
using standardized case definitions and integrated laboratory testing;
strong networks of connected public health and clinical laboratories;
efficient and comprehensive nationally notifiable disease surveillance
systems; targeted surveillance in specific high risk settings and
vulnerable populations; sustained health care capacity monitoring; and
enhanced clinical surveillance, among others. Surveillance systems need
to be complemented with high quality and timely outbreak investigations
and studies to obtain information not routinely available from ongoing
systems.

There are also several structural or enabling factors that are critical
to the success of any sustainable surveillance. These include strong
governance and leadership, sustainable financing and workforce, and
integration of data standards and appropriate innovations to promote
timely and collaborative analyses of surveillance information from
multiple sources. Given the complexity of the current respiratory
surveillance landscape, national authorities now need an evidence-based
framework to help their countries rapidly (Figure 2):

* identify priority respiratory virus surveillance objectives;

* identify the surveillance approaches that have been used to meet these
objectives;

* prioritize required enhancements of existing surveillance;

* develop implementation plans according to the national context,
resources and needs;

* strengthen collaborative synergies between surveillance systems; and

* prioritize and target technical assistance and financial investments
from partners\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2: The vision and aims of the mosaic surveillance
framework}

\emph{Leveraging global expertise and experiences to develop the mosaic
framework}

The mosaic surveillance framework was developed by drawing on the
experiences of a technical working group (TWG) that included WHO subject
matter experts from more than 20 teams / departments at WHO
headquarters, and members from WHO regional offices (RO) in all six WHO
regions. To further obtain experiences and perspectives from countries
of all socio-economic levels, a secretariat supported WHO Regional
Offices as they worked with Country Offices and Ministry of Health
partners to implement surveys and gather data on priority objectives,
surveillance systems currently used to meet those objectives, and
priority surveillance enhancements needed. The Regional Offices also
convened regional consultations and focused discussions with countries,
informed by surveys, to obtain input for the global consultation. WHO
headquarters then hosted a global consultation entitled ``'Crafting the
Mosaic': Resilient surveillance systems for respiratory viruses of
pandemic potential'' on 10 \& 11 May 2022. This consultation included
340 in-person and on-line attendees including those working in
surveillance at the country level, and representatives from WHO Country
Offices, all six Regional Offices, WHO headquarters, and external
partner organizations. The framework incorporated iterative feedback
from the TWG, the WHO COVID-19 incident management team leadership, and
external subject matter experts from the United States Centers for
Disease Control and Prevention, The European Centre for Disease
Prevention and Control, The Global Fund, The Bill and Melinda Gates
Foundation, and The Rockefeller Foundation. The secretariat also
collected case studies by working with WHO Regional Offices to obtain
examples of implementation of different surveillance systems and studies
to meet priority objectives. These case studies provide national
authorities with examples of the use of different systems to help them
move from a theoretical to practical level.

\emph{Coordination with existing surveillance guidance and initiatives}

The mosaic surveillance framework is in line with the collaborative
surveillance component of the WHO Global Architecture for Health
Emergency Preparedness, Response and Resilience (HEPR) (4). This tool
will evolve to ensure it meets countries' needs and synchronizes with
the ongoing discussion for the pandemic convention accord + (CA+). This
tool also supports the International Health Regulations (IHR) 2005,
specifically the core capacity requirements for surveillance and
response and the National Action Plans for Health Security (5) and will
be adapted if the ongoing discussion related to the revision of the
IHR(2005) requires it. Importantly, this framework is a conceptual
structure that underpins and supports current initiatives and does not
supersede any existing global or regional normative surveillance
guidance. Rather, it is intended to place the systems represented by
existing guidance into a context where they may address the objectives
for which they are best intended. The framework presents appropriate
uses of existing systems for respiratory virus surveillance and refers
to existing global and regional surveillance-specific guidance and
operating procedures wherever they exist.

\emph{Implementation during the coming year}

The specific tools to help countries implement the mosaic surveillance
framework will include those to help prioritize respiratory surveillance
objectives, map existing systems to priority objectives; and to identify
priority enhancements needed. However associated tools will also help
national authorities consider the need to strengthen broader enabling
structures for surveillance in their countries.

Our vision is that all countries develop well-coordinated mosaics of
multiple fit-for-purpose surveillance approaches that address priority
surveillance objectives for influenza, SARS-CoV-2, RSV, and other
respiratory viruses of epidemic and pandemic potential according to
country context. Respiratory viruses serve as a prototypical example of
the way surveillance systems can work together resiliently to provide a
comprehensive picture of disease emergence, spread and impact. There are
several respiratory viruses that have important commonalities in terms
of virological, epidemiological and clinical surveillance approaches.
However, there are areas where this framework has applicability beyond
respiratory viruses, and in some cases beyond respiratory pathogens. The
next respiratory pandemic remains imminent, and the time is now to apply
lessons learned to assure that newly strengthened and properly focused
routine surveillance may better support epidemic, pandemic, and other
emergency monitoring needs.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Statement on the eleventh meeting of the International Health
  Regulations (2005) Emergency Committee regarding the coronavirus
  disease (COVID-19) pandemic (who.int)
\item
  WHO Unity Studies Unity Studies: Early Investigation Protocols
  (who.int)
\item
  Public health surveillance for COVID-19: interim guidance. Geneva:
  World Health Organization; 2022
  https://www.who.int/publications/i/item/WHO-2019-nCoV-SurveillanceGuidance-2022.2
  accessed 21 January 2023.
\item
  Strengthening the Global Architecture for Health Emergency
  Preparedness, Response and Resilience (who.int)
\item
  World Health Organization strategy (2022-2026) for the National
  Action Plan for Health Security (who.int)
\end{enumerate}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure1/Figure1}

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\includegraphics[width=0.70\columnwidth]{figures/Figure2/Figure2}

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