Postpandemic Sentinel Surveillance of Respiratory Diseases in the Context of the World Health Organization Mosaic Framework: Protocol for a Development and Evaluation Study Involving the English Primary Care Network 2023-2024

Abstract

Background: Prepandemic sentinel surveillance focused on improved management of winter pressures, with influenza-like illness (ILI) being the key clinical indicator. The World Health Organization (WHO) global standards for influenza surveillance include monitoring acute respiratory infection (ARI) and ILI. The WHO's mosaic framework recommends that the surveillance strategies of countries include the virological monitoring of respiratory viruses with pandemic potential such as influenza. The Oxford-Royal College of General Practitioner Research and Surveillance Centre (RSC) in collaboration with the UK Health Security Agency (UKHSA) has provided sentinel surveillance since 1967, including virology since 1993.

Objective: We aim to describe the RSC's plans for sentinel surveillance in the 2023-2024 season and evaluate these plans against the WHO mosaic framework.

Methods: Our approach, which includes patient and public involvement, contributes to surveillance objectives across all 3 domains of the mosaic framework. We will generate an ARI phenotype to enable reporting of this indicator in addition to ILI. These data will support UKHSA's sentinel surveillance, including vaccine effectiveness and burden of disease studies. The panel of virology tests analyzed in UKHSA's reference laboratory will remain unchanged, with additional plans for point-of-care testing, pneumococcus testing, and asymptomatic screening. Our sampling framework for serological surveillance will provide greater representativeness and more samples from younger people. We will create a biomedical resource that enables linkage between clinical data held in the RSC and virology data, including sequencing data, held by the UKHSA. We describe the governance framework for the RSC.

Results: We are co-designing our communication about data sharing and sampling, contextualized by the mosaic framework, with national and general practice patient and public involvement groups. We present our ARI digital phenotype and the key data RSC network members are requested to include in computerized medical records. We will share data with the UKHSA to report vaccine effectiveness for COVID-19 and influenza, assess the disease burden of respiratory syncytial virus, and perform syndromic surveillance. Virological surveillance will include COVID-19, influenza, respiratory syncytial virus, and other common respiratory viruses. We plan to pilot point-of-care testing for group A streptococcus, urine tests for pneumococcus, and asymptomatic testing. We will integrate test requests and results with the laboratory-computerized medical record system. A biomedical resource will enable research linking clinical data to virology data. The legal basis for the RSC's pseudonymized data extract is The Health Service (Control of Patient Information) Regulations 2002, and all nonsurveillance uses require research ethics approval.

Conclusions: The RSC extended its surveillance activities to meet more but not all of the mosaic framework's objectives. We have introduced an ARI indicator. We seek to expand our surveillance scope and could do more around transmissibility and the benefits and risks of nonvaccine therapies.

Keywords: COVID-19; World Health Organization; computerized medical record system; human influenza; influenza vaccines; pandemic; phenotype; respiratory syncytial virus; respiratory tract infections; sentinel surveillance; vaccination.

Figure 1

Tool used to facilitate the intentional identification of Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) refsets. The lower figure demonstrates how SNOMED CT supertypes and subtypes are included or excluded using the Helper Tool.

Figure 2

Royal College of General Practitioners Research and Surveillance Centre reference lab virological surveillance overview. GISAID: Global Initiative on Sharing All Influenza Data; RSV: respiratory syncytial virus; RT-PCR: reverse transcription polymerase chain reaction; UKHSA: UK Health Security Agency; WHO: World Health Organization.

Figure 3

Research and Surveillance Centre recommendations for classifying the etiology of respiratory symptoms or signs in people presenting to primary care. COPD: chronic obstructive pulmonary disease; ILI: influenza-like illness; LRTI: lower respiratory tract infection; SoB: shortness of breath; URTI: upper respiratory tract infection.

Figure 4

Research and Surveillance Centre recommendations for classifying possible acute respiratory infection presentation to primary care. The coding sequence is to promote improved recording of influenza-like illness cases and exacerbations of chronic respiratory disease. COPD: chronic obstructive pulmonary disease.

Figure 5

Vaccine exposure data, taken from our observatory displaying graphically as well as numerically the practice levels of vaccine uptake (2022-2023 season). GP: general practitioner; RSC: Research and Surveillance Centre.

Figure 6

Circulating virology data taken from our observatory showing the percentage of positive samples by viral strain for Research and Surveillance Centre (RCS) general practitioners (GPs) combined and an example of an individual practice (2022-2023 season). hMPV: human metapneumovirus; RSV: respiratory syncytial virus.

Figure 7

Serology data taken from our observatory and dashboard showing the number of samples collected by age band for Research and Surveillance Centre general practitioners combined (2022-2023 season).

Figure 8

Virological surveillance data workflow. Samples are taken in practice. They pass through the local pathology laboratory to the UK Health Security Agency (UKHSA) viral reference laboratory at Colindale. Virology results go back to the general practitioner (GP) and patient and also into the Research and Surveillance Centre (RSC) database. ICE: Integrated Clinical Environment; LIMS: Laboratory Information Management System.

Figure 9

Weekly incidence of scarlet fever or streptococcal sore throat presenting to the English primary care sentinel network practices from 2010 to 2023. The incidence in the last quarter of 2022 was higher than that seen in the previous 10 years.

Figure 10

The assembly of data since 1967 within the biomedical resource. Birmingham Research Unit (BRU) was the location of the Research and Surveillance Centre up to 2013. Up to 1994, spreadsheets were loaded into an Access database, which was then replaced by structured query language (SQL). The Real World Evidence (RWE) server was set up in 2013.

Figure 11

Change in the rate of presentation of patients with influenza-like illness to primary care from 1967 to 2022. The year of introduction of different flu vaccines has been added, and the data are 4 weekly averages. The point “65+” indicates the introduction of the flu vaccine for all people aged 65 years or older. “LAIV” indicates the introduction of the live attenuated influenza vaccine for school children. “aTIV” indicates the introduction of the adjuvanted trivalent influenza vaccine to improve vaccine effectiveness in people aged 65 years or older. BRU: Birmingham Research Unit; RWE: Real World Evidence; SQL: structured query language.