Digitalizing and Upgrading Severe Acute Respiratory Infections Surveillance in Malta: System Development

Abstract

Background: In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe.

Objective: We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities.

Methods: Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes.

Results: By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%).

Conclusions: The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

Keywords: COVID-19; digital health; disease prevention; disease surveillance; electronic record; epidemiology; health data; health system; monitoring; pandemic; patient data; public health; public hospital; surveillance.

Figure 1

Flowchart describing SARI surveillance procedures in Malta. Panel A shows the system in place in October 2020. Panel B shows the system in place from February 1, 2021, which included data required by the ECDC protocol. Panel C shows the system currently in place, where manual extraction is required only for symptoms and comorbidities. ECDC: European Centre for Disease Prevention and Control; SARI: severe acute respiratory infections.

Figure 2

Weekly SARI case counts according to COVID-19 status. SARI: severe acute respiratory infections.

Figure 3

Upset plot showing the most common symptom groupings for patients with severe acute respiratory infections (SARI).

Figure 4

Comparing SARI definitions: patients with COVID-19 detected by month from February 1 to November 30, 2021. Percent of patients who are COVID-19 positive detected by triage using (A) Maltese SARI "confirmed" and "possible" definitions, (B) Maltese SARI "confirmed" definition, and (C) the World Health Organization's definition. SARI: severe acute respiratory infections.

Figure 5

Comparing SARI definitions: patients with COVID-19 detected by age group from February 1 to November 30, 2021. Percent of patients who are COVID-19 positive detected by triage using (A) Maltese SARI "confirmed" and "possible" definitions, (B) Maltese SARI "confirmed" definition, and (C) the World Health Organization's definition. SARI: severe acute respiratory infections.