Evaluation of Communicable Disease Surveillance in the Republic of the Marshall Islands

BACKGROUND: The Republic of the Marshall Islands (RMI) is an independent country in the northern Pacific Ocean with 53,158 people. Under the Compact of Free Association, RMI citizens may travel, work, and reside in the U.S. without immigration health examinations. Communicable diseases in RMI have previously resulted in transmission to the U.S., including measles, Hansen’s disease, and tuberculosis. To help strengthen the RMI Ministry of Health (MOH) capacity to detect and control infectious disease outbreaks, our assessment focused on notifiable disease and syndromic surveillance systems.

METHODS: An on-site assessment included direct observation and semi-structured interviews of key stakeholders, including administrators, physicians, public health officials, and laboratorians in Majuro and Ebeye, serving 74% of RMI’s population. Using the CDC surveillance evaluation guidelines, we concentrated on the components of data collection, sources, management, and analysis for notifiable disease and syndromic surveillance systems. Performance measures focused predominately on simplicity, flexibility, and data quality.

RESULTS: Most surveillance-associated data are recorded in paper logbooks, and primarily reported by nurses (Majuro) and physicians (Ebeye). Notifiable disease and syndromic data are sent to the MOH surveillance point-of-contact for final analysis and weekly reports to stakeholders. Simplicity is hampered by inconsistent syndromic classifications and unclear national reporting mechanisms. The successful early detection of a dengue outbreak in 2011 demonstrated flexibility to adapt to a new health-related event. Different reporting sources and a lack of consistent case definitions between Majuro and Ebeye impact data quality. Limited laboratory confirmatory testing capacity reduces data completeness and validity; only 10 of 19 notifiable diseases have confirmatory laboratory testing available on-island. Compared to U.S. health departments, epidemiologic, laboratory, and informatics capacity is limited.

CONCLUSIONS: Notifiable disease surveillance is limited by laboratory testing capacity, paper-based systems, and inconsistent response protocols in the RMI. Communicable disease surveillance may be enhanced by: 1) standardizing syndromic data collection and reporting between Majuro and Ebeye; 2) simplifying reporting mechanisms for notifiable diseases; 3) strengthening epidemiologic capacity at the national level; 4) developing standard investigation protocols for syndromic alerts; and 5) comparing syndromic trends with notifiable disease reports to adjust thresholds. Syndromic surveillance in resource-poor settings with limited confirmatory testing may help prioritize additional investigation. Public health informatics consultation will support ongoing development of a national electronic health information system in the RMI.