Integrating existing datasets to manage key health priorities: the case of mosquito-borne disease

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1 HEALTH INFORMATION SYSTEMS KNOWLEDGE HUB DOCUMENTATION NOTE SERIES NUMBER 10 NOVEMBER 2010 Integrating existing datasets to manage key health priorities: the case of mosquito-borne disease Dr Sarah Goater Health Information Systems Knowledge Hub, School of Population Health, University of Queensland Health Information Systems Knowledge Hub School of Population Health University of Queensland KNOWLEDGE HUBS FOR HEALTH Strengthening health systems through evidence in Asia and the Pacific

2 ABOUT THIS SERIES The objective of the HIS Hub Documentation Series is to document in detail the methods and findings of the HIS Knowledge Hub s activities in partner countries. Health Information Systems Hub The Documentation Series also serves to describe the state of the health (HIS) information Knowledge system Hubin a number of Asia and Pacific Island countries. This series provides a baseline for comparison of HIS between countries. It also provides a preliminary diagnostic analysis for use by countries in determining areas requiring improvement. The target audiences for these mappings are all stakeholders with an interest in the functioning or development of HIS, specifically those working in the Pacific and Asia region. The Series also reports on work in progress, particularly for large, complex or multi-year HIS Hub initiatives, or on specific components or aspects of such projects that may be of more immediate relevance to stakeholders The opinions or conclusions contained in the Documentation Series are those of the authors and do not necessarily reflect the views of institutions or governments. ACKNOWLEDGEMENTS The HIS Hub team for their support of this research, in particular Maxine Whittaker and Audrey Aumua for their contribution and expert guidance. 2 DOCUMENTATION NOTE SERIES NUMBER 10 NOVEMBER 2010

3 ACRONYMS EWS HIS MBD NNDSS PICT Early Warning System Health Information Systems Mosquito Borne Disease National Notifiable Disease Surveillance System Pacific Island Countries and Territories Health Information Systems Hub (HIS) Knowledge Hub 3 NUMBER 10 NOVEMBER 2010 DOCUMENTATION NOTE SERIES

4 ABSTRACT Under current climate change projections the capacity to provide safe drinking water to Australian communities will be challenged. Part of this challenge is the lack of an adaptive governance strategy that transcends jurisdictional boundaries to support integrated policy making, regulation or infrastructual adaption. Consequently, some water-related health Health hazards Information may Systems not be adequately Hub captured or forecast under existing water resource management policies to ensure sate water supplies. Given the (HIS) high degree Knowledge of spatial Hub and temporal variability in climate conditions experienced by Australian communities, new strategies for national health planning and prioritisation for safe water supplies are warrented. The challenges facing public health in Australia will be to develop flexible and robust governance strategies that strengthen public health input to existing water policy, regulation and surveillance infrustructure through: (i) proactive risk planning, (ii) adopting new technologies and (iii) intersectoral collaborations. The proposed approach could assist policy makers avert or minimise risk to communities arising from changes in climate and water provisions both in Australia and in the wider Asia Pacific region. INTRODUCTION The world-wide success of Health Information, Systems (HIS) relies on the effective transformation of health data into information products that can be readily used to monitor and improve health outcomes. However, for the 22 island nations that comprise the Pacific Islands Countries and Territories (PICTs), regional, social, economic and environmental factors confounded by global climate changes, pose significant challenges to an already stretched health care and HIS system (Lum On et al 2009). The populations, cultures, economies and politics of the PICTs are extremely diverse, leading to numerous and prolonged HIS impediments at local and regional scales. Despite some improvements in recent years, geographic isolation continues to complicate the provision of basic health services, education and training leaving much room for improvement (Finau 1994). Readily available, up-to-date information and data remain crucial for planning efficient, cost effective solutions to public health issues. So, do opportunities exist to rethink current approaches to HIS planning and management - and respond to the future challenges of climate change? Here, the argument that the principles outlined in Part 2 of the broader paper (abstract appears in annex A) (Goater et al 2011) could readily be adopted to increase community resilience to many water-related health challenges across the PICTs is promulgated. Further, it is proposed the overwhelming prospect of reforming existing HIS might be strategically circumvented by building collaborations with wealthy neighbouring countries, such as Australia, who face similar health risks due to climate changes. The diversity and environmental heterogeneity of Australian communities, combined with a strong health care system, provides numerous opportunities for our nation to become a working analogue for our Asia-Pacific neighbours (National Broadband Network 2010). Many Australian communities exhibit structural and social vulnerabilities paralleling those of PICTs. Indeed, both regions experience spatial and temporal extremes in weather conditions, such as high temperatures, tropical cyclones and flooding that can leave them at risk of water-related communicable and infectious diseases (Goater et al 2011). Consequently, a common need exists for the development of early warning systems that strengthen public health policy and triggers for local and regional health action. In Australia, greater population densities in urban areas provide economies of scale to improve existing health surveillance and management tools (the National Broadband Network (Bambrick et al 2011), for example) to all Australians, including remote communities leading to the potential to apply lessons learned to our Pacific neighbours (National Broadband Network 2010). The principles of such an approach are discussed briefly below in the context of mosquito borne disease (MBD) risk, although they have broader application to other health priorities such as water-borne diarrhoeal disease. INFORMATION NEEDS FOR MANAGING MOSQUITO-BORNE DISEASE Strategies to forecast, control and prevent emerging mosquito-borne health risks are considered a priority research area in the Australasia-Pacific region. Climate change is predicted to result in the geographic expansion of MBD burden such as malaria and dengue, with parts of Australia also to encounter spread of Ross River virus, Barmah Forest virus, and Arboviral encephalitides (Zang et al 2008; Hales et al 2002; Harley et al 2001; Harley et al 2011). It is expected that warmer temperatures will increase virus longevity, speed up vector development and feeding frequency, and amplify interactions with non-immune reservoir host populations. Cumulatively, these factors result in increased human exposure to the risk of infection (Harley et al 2011; Carver et al 2009). The spatial-temporal complexity of MBDs requires tools by which to prioritise the best use of public health funding and resources. Importantly, as the epidemiology of disease risk evolves, it will be imperative that public outreach programs increase community awareness of these changes through the communication of appropriate information on ways to increase community resiliance (Wener et al [under review]).indeed, health interventions designed to combat mosquito productivity and human exposure will not be ubiquitous for all species in space or time (Wener et al [under review]). As such, a need exists to develop flexible, cost-effective predictive tools that strengthen the capacity of public health services to forecast future MBD burden but also increase community resilience by implementing appropriate adaptive strategies. Four key steps designed to improve community resilience progressively are presented below. 4 DOCUMENTATION NOTE SERIES NUMBER 10 NOVEMBER 2010

5 Step 1 - Prioritise the use and integration of existing interdisciplinary datasets to provide a comprehensive knowledge base from which to focus HIS data collection, interpretation and communication - without increasing demand on an already stretched health care system. By analysing public health surveillance data in Australia with those hypothesised environmental drivers of vector populations, potential exists to develop hazard maps to identify, classify and rank those communities mostly likely to be exposed to MBDs. In contrast to the PICTs, Australia has strong national surveillance for the detection and management of MBDs. By law, all MBD cases must be reported to local, state, and national Health Health Information Systems Hub Authorities and lodged in the National Notifiable Disease Surveillance System (NNDSS) (NNDSS 2010). This passive surveillance system is used (HIS) Knowledge Hub in conjunction with other HIS tools to inform mosquito control programs, identify patterns in the disease and areas at risk, as well as for developing public health interventions (Communicable Disease Network Australia 2009). In addition to these HIS, Australia has a rapidly developing network of high quality environmental and climate data that provide invaluable opportunities to strengthen the adaptive capacity of communities to the threat of MBDs (Goater et al 2011). National, state and regional-scale datasets on known environmental drivers of vector populations (rainfall, temperature, tide, humidity, wind patterns, for example.) can readily be used to describe variability in likely breeding habitats across bioregions (climate, water bodies, land use, for example). By integrating these environmental datasets with existing HIS, preliminary hazard maps might then be prepared to estimate likely risk of MBDs based on environmental characteristics, even where health information is lacking. Step 2 - Develop a series of environmental indicators that consider the interplay among the vector, reservoir, host and the environment - to be used as triggers for proactive public health action. By categorising and prioritising at risk areas in Step 1, multi-disciplinary research efforts might then be focused on improving knowledge concerning the biological and ecosystem interactions that determine vector-host exposure in high risk communities. The purpose here is to identify useful environmental health indicators that might be incorporated into community-level surveillance and/or the development of public health Early Warning System (EWS). Model-driven EWSs based on seasonal climatic forecasts are increasingly being attempted to control and prevent risk of malaria and dengue better. However, uncertainties relating to variability in lag times and case onsets need to be addressed relative to environmental and ecosystem drivers (Girgin et al 2005). Development of holistic models that are geographically restrictive and account for local variations in vector-host epidemiology and ecology would facilitate reduction of uncertainty in predicting future disease risk - by continually improving public health indicators of likelihood and consequence of exposure to MBDs. Knowledge gaps currently include identification and tracking of disease risk relative to: environmental drivers; factors that regulate mosquito populations such as predation, competition for space, habitat conditions and available food resources; and potentially surrounding land use practices, as well as proximity to humans and reservoir hosts (Harley et al 2011; Carver et al 2009; Wener et al [under review]). This information ought to be fed back into the hazard profiling tools used in Step 1, creating a dynamic risk mapping tool that can be used to generate public health notices that inform communities of relative risk and appropriate intervention strategies. Step 3 - Determine how MBD risks in communities relate to their adaptive capacity under varying public health intervention scenarios. A limitation of existing EWSs is that they do not take into account the moderating effect of public health interventions on MBD prevalence. In order to identify and assess the vulnerability of Australian and PICT communities to MBDs driven by climate change impacts, there needs to be a baseline of information to determine the ability of those communities to minimise health risks relative to MBD exposure. A key objective here is to identify clear links between EWS forecasts of MBD risk relative to community resilience, as determined by the existence and efficacy of adaptive strategies. This would require intelligence gathering at the community-level on environmental hazards linked to MBD in Step 2 along with adaptive strategies already in place i.e. actions, operations, infrastructure that provide the community with increased ability to adapt and therefore reduce or eliminate the adverse effects of MBDs. For example: mosquito management plans/programs (spraying, larvicides, clean ups), environmental health data collection on breeding sites proximal to residential dwellings (natural and/or anthropogenic), or co-ordinated public health interventions (bed nets, educational programs, for example). In the first instance, this intelligence gathering exercise need not require intensive on the ground operational support but more so desktop and phone consultation. Again, this information could be fed back into the hazard profiling tools used in Step 1, to re-evaluate MDB risk relative to community resilience to further prioritise and focus public health resources where they are most needed. Furthermore, opportunity exists to prioritise limited public health resources by establishing good-practice flagships for other at risk communities based on environmental circumstances. Step 4 - Close the HIS loop by feeding data and knowledge gained through steps 1-3 back into climate change projections to reduce uncertainty and elucidate future health challenges and corresponding health policy strategies. To develop short-, medium- and longer-term strategies for improving community resilience to future MBD challenges, regional policy makers require simple tools that best inform community-scale risk assessment under varying climate change scenarios. Indeed, predicting future disease occurrence for such a purpose will be surrounded by considerable uncertainty (e.g. the quality of public health surveillance data and the changing influence of future biological and socioeconomic adaptations on environmental-health relationships are all contributing factors). Yet, these uncertainties are not insurmountable if new statistical methods identified in Part 2 of the broader paper (Goater et al 2011) are embraced. The priority is to utilise those tools that can account for all known assumptions and uncertainties within a single theoretical environment, and that can be easily updated with new information and prioritised where additional data collection are required to: (i) reduce uncertainty and (ii) strengthen MBD risk profiles. This is another area where opportunity exists for Australia to support local and regional health planning across the PICTs by providing 5 NUMBER 10 NOVEMBER 2010 DOCUMENTATION NOTE SERIES

6 statistical support which in the longer term builds local capacity. In conclusion, by working collaboratively with neighbour countries such as Australia to identify what information is required to meet their health care needs best, the PICTs public health sector would be in a stronger position to develop proactive health policy and interventions to existing and emerging water-related health risks. However, to do so, a dialogue among regional HIS services, health care practitioners, donor groups and existing researchers needs to be initiated. Existing programs such as the AusAID funded HIS Knowledge Hub may provide a contact point for such a dialogue, although collaborations ought to be encouraged Health beyond Information broader-scale Systems planning Hub forums for policy development to include local governments who are ultimately handed the responsibility for health care provision (HIS) Knowledge and management. Hub REFERENCES Australian Government Department of Health and Ageing website. Surveillance systems. ( Content/cda-state-legislation-links.htm). Accessed 8 April 2009 Bambrick HJ, Capon AG, Barnett GB et al., Climate change and health in the urban environment: Adaptation opportunities in Australian cities. Asia Pac J Public Health. 2011;23 (in press) Carver S, et al. The influence of hosts on the ecology of arboviral transmission: Potential mechanisms influencing dengue, Murray Valley encephalitis and Ross River virus in Australia. Vector-Borne and Zoonotic Diseases 2009; 9: Communicable Diseases Network Australia Surveillance systems.. Finau National health information systems in the Pacific Islands: In search of a future. Health Policy and Planning 9(2): Girgin S, Unlu K, Yetis U Use of GIS as a supporting tool for envrionmental risk assessment and emergency response. In: Comparative Risk Assessment and Environmental Decision Making, Vol. 38, (Linkov I, Ramadan AB, eds):springer Netherlands, Goater S, Cook A, Hogan Aet al., Strategies to strengthen public health inputs to water policy in response to climate change: An Australian perspective, Asia Pac J Public Health. 2011;23 (in press) Hales S, dewet N, Maindonoald J et al. Potential effect of population and climate change son global distribution of dengue fever: An empirical model. Lancet. 2002; 360(9336): Harley D, Bi P, Hall G et al., Climate change and infectious disease in Australia: Future prospects, adaptation options and research priorities. Asia Pac J Public Health. 2011;23 (in press) Harley D, Sleigh A, Ritchie S et al., Ross River virus transmission, infection and disease: a cross-disciplinary review. Clin Microbiol Rev. 2001; 14(4): Lum On M, Bennett V, Whittaker M Issues and Challenges for HIS In Pacific Islands and Territories: Findings from the Pacific Health Information Network Meeting 29 September- 2 October 2009 and the Pacific Health Information Systems Development Forum 2-3 November NBN. National Broadband Network. Avaiable from: [Accessed, November 26, 2010] NNDSS. National Notifiable Diseases Surveillance (NNDSS)[accessed 2010 June 25, 2010]; Available from: main/publishing.nsf/content/cda-surveil-nndss-nndssintro.htm. Thomas MC, Doblas-Reyes FJ, Mason SJ et al. Malaria early warning systems based on seasonal climate forecasts for multi-model ensembles. Nature. 2006; 439(7076): Werner A, Goater S, Carver S et al., Environmental drivers of Ross River Virus in south-east Tasmania, Australia: Towards strengthening public health interventions. Epidemiology and Infection [under review] Zang Y, Bi P, hiller JE. Climate change and the transmission of vector-borne diseases: A review. Asis Pac J Public Health. 2008; 20(1): DOCUMENTATION NOTE SERIES NUMBER 10 NOVEMBER 2010

7 KNOWLEDGE HUBS FOR HEALTH Strengthening health systems through evidence in Asia and the Pacific A strategic partnerships initiative funded by the Australian Agency for International Development The Nossal Institute for Global Health