On 24 March 1882, Robert Koch announced his discovery of Mycobacterium tuberculosis as the causal agent of tuberculosis (TB) [1]. For centuries, the disease has claimed hundreds of thousands of lives, bringing economic hardship to patients, their families and health systems. Looking back from where we stand today, on 24 March 2023, World TB Day, we have made great progress in tackling this preventable and curable disease, including progress on the social and economic factors linked to TB.

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The COVID-19 pandemic has exposed weaknesses in disease surveillance in nearly all countries. Early identification of COVID-19 cases and clusters for rapid containment was hampered by inadequate diagnostic capacity, insufficient contact tracing, fragmented data systems, incomplete data insights for public health responders, and suboptimal governance of all these elements. Once SARS-CoV-2 became widespread, interventions to control community transmission were undermined by weak surveillance of cases and insufficient national capacity to integrate data for timely adjustment of public health measures.1Arvisais-Anhalt S Lehmann CU Park JY et al.What the coronavirus disease 2019 (COVID-19) pandemic has reinforced: the need for accurate data.Clin Infect Dis. 2021; 72: 920-923Crossref PubMed Scopus (20) Google Scholar, 2Lewis D Why many countries failed at COVID contact-tracing—but some got it right.Nature. 2020; 588: 384-387Crossref PubMed Scopus (100) Google Scholar Although some countries had little or no reliable data, others did not share data consistently with their own populations and with WHO and other multilateral agencies. The emergence of SARS-CoV-2 variants has highlighted inadequate national pathogen genomic sequencing capacities in many countries and led to calls for expanded virus sequencing. However, sequencing without epidemiological and clinical surveillance data is insufficient to show whether new SARS-CoV-2 variants are more transmissible, more lethal, or more capable of evading immunity, including vaccine-induced immunity.3Wadman M United States rushes to fill void in viral sequencing.Science. 2021; 371: 657-658Crossref PubMed Scopus (5) Google Scholar, 4WHOSARS-CoV-2 genomic sequencing for public health goals interim guidance. World Health Organization, Geneva2021Google Scholar Public health decision making relies on real-time, accurate surveillance.5Thacker SB Qualters JR Lee LM Centers for Disease Control and PreventionPublic health surveillance in the United States: evolution and challenges.MMWR Suppl. 2012; 61: 3-9Google Scholar As communities and economies struggle to recover from the consequences of these surveillance deficiencies, now is the time for countries and multilateral agencies to take a hard look at what failed and to act boldly to implement the necessary improvements to disease surveillance. Future disease surveillance should comprise well integrated national systems based on five principles (table). First, a strong surveillance foundation should monitor the population in a systematic, consistent, and statistically sound way. Second, surveillance systems must incorporate laboratory confirmation appropriately scaled for different diseases and risks. Third, surveillance systems must be digitised, with unique health identifiers to connect individual-level data and with privacy safeguards. Fourth, surveillance programmes must use standardised case definitions and common data elements, with appropriate access for the public, local and national health authorities, regional bodies, and WHO. Fifth, disease surveillance must be adequately financed.TableCore principles for integrated disease surveillanceBenefitsImplementation requirementPopulation-basedDenominators for mortality rates and disease burdenCRVS or sample registration systemLaboratory confirmationCases accurately trackedCapacity to scale testing and sequence pathogensDigital dataSystems interconnected and privacy protectedUnique health identifiers, standard metadata, web accessibleData transparencyVisibility of all national threats by NPHIs and by WHO for transnational threatsAutomated reporting to NPHI with a subset to WHO and regional bodiesAdequate financingSustainable country-owned systemsInvest US$1–4 per capita annuallyCRVS=civil registration and vital statistics. NPHI=national public health institute. Open table in a new tab CRVS=civil registration and vital statistics. NPHI=national public health institute. Interpretation of disease surveillance data needs population representativeness, denominators, and historical baseline data. Civil registration and vital statistics (CRVS) systems are important for population estimation and understanding excess mortality but have historically taken years to build. Many countries that lack or have inadequate CRVS systems need to accelerate their development in alignment with the recommendations in the WHO SCORE for Health Data Technical Package report.6WHOSCORE for Health Data Technical Package. Global report on health data systems and capacity, 2020. World Health Organization, Geneva2021Google Scholar In the meantime, representative sample registration systems can provide denominator and mortality data and can be designed to support the development of CRVS systems. Such sample registration systems are established in several middle-income countries and are being implemented in some low-income countries, such as Mozambique and Sierra Leone.7Nkengasong J Gudo E Macicame I et al.Improving birth and death data for African decision making.Lancet Glob Health. 2020; 8: e35-e36Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar Multiple surveillance systems can be integrated on such a population-representative foundation, according to the priorities of the country and leveraging internal resources, such as surveillance programmes run by academic and non-governmental institutions. A fully integrated surveillance system could include integrated disease surveillance and response, including COVID-19 case reporting; pathology-based cause of death surveillance;8Mwananyanda L Gill CJ MacLeod W et al.Covid-19 deaths in Africa: prospective systematic postmortem surveillance study.BMJ. 2021; 372: n334Crossref PubMed Scopus (107) Google Scholar electronic health and laboratory record data transfer; serological surveillance; vaccine adverse events reporting; epizootic and food safety surveillance systems on the One Health model; participatory community surveillance; and disease-specific systems for HIV, tuberculosis, malaria, vaccine-preventable diseases, and many others. For data linkage it is crucial that all systems are digital and that unique health identifiers are assigned to everybody in the population. Privacy protection, including review by privacy watchdogs, must be established. Surveillance data reviews should trigger rapid public health action locally. National public health institutes (NPHIs) should be charged with collating and analysing data nationally and coordinating or undertaking modelling of disease patterns and pathogen evolution to guide public health suppression measures, border policies, vaccine development and deployment, and treatment protocols. NPHIs should have the mandate and systems to share information about transnational health threats with international bodies under the International Health Regulations (2005), and these bodies must commit to full transparency of the data they receive. Additionally, NPHIs should monitor key performance indicators, such as time to detect, report, investigate, and control disease outbreaks. Adequate financing and the creation of a sustainable market will be needed for the establishment and continual maintenance of surveillance infrastructure. Countries should expect to spend about US$1–4 per capita annually on disease surveillance infrastructure and personnel.9Craven M Sabow A Van der Veken L Wilson M Not the last pandemic: investing now to reimagine public-health systems. McKinsey & Company, 2021https://www.mckinsey.com/industries/public-and-social-sector/our-insights/not-the-last-pandemic-investing-now-to-reimagine-public-health-systemsDate accessed: May 13, 2021Google Scholar For low-income and middle-income countries, substantially more start-up investment is likely to be required to strengthen laboratory capacities, data systems, and human resource capacity, as part of larger investments in health systems strengthening; some of this cost will need to be met by donors and high-income countries. Dedicated investments will also be needed to ensure that high-risk populations, especially in humanitarian contexts, are not excluded from improved surveillance systems. The amounts are considerable but represent a small proportion of the $249 per person average annual military spending and the more than $10 trillion in estimated economic costs from inadequate disease surveillance.10Tian N Kuimova A Lopes Da Silva D Wezeman PD Wezeman ST Trends in world military expenditure, 2019. SIPRI Fact Sheet.https://www.sipri.org/sites/default/files/2020-04/fs_2020_04_milex_0.pdfDate: April, 2020Date accessed: May 13, 2021Google Scholar Piecemeal, antiquated public health surveillance must be robustly transformed into a modern system. As the COVID-19 pandemic has shown, weak surveillance limits the ability of countries to detect and rapidly respond to health threats and harness the benefits from innovations such as pathogen genomic sequencing, mRNA vaccines, and novel antivirals. Bold changes to implement fully interconnected disease surveillance are needed to manage the risks posed by SARS-CoV-2 variants and future pandemics. OWM is the Director of Health Emergency Information and Risk Assessment, WHO. XA is the Director of the Center for Epidemiology and Health Policy, Universidad del Desarrollo Chile. AA is the Director of the European Centre for Disease Prevention and Control. ISF is the Assistant Director General of Emergency Response, WHO. TF is the President of Resolve to Save Lives. CI is the Director of the Nigeria Centre for Disease Control. E-kJ is the Commissioner of the Korea Disease Control and Prevention Agency. BM is the Senior Program Officer, Surveillance and Epidemiology, Bill & Melinda Gates Foundation. JN is the Director of the Africa Centres for Disease Control and Prevention. AS is the Principal Deputy Director of the US Centers for Disease Control and Prevention. LHW is the President of the Robert Koch Institute. SFD is the COVID-19 Response Lead, Bill & Melinda Gates Foundation. All authors declare no competing interests. Many public health colleagues have contributed to the approach described in this Comment; we gratefully acknowledge Torsten Semmler (Robert Koch Institute); David Blazes, Samantha Dolan, Vivian Hsu, Georgina Murphy, and Carolyn Wendell (Bill & Melinda Gates Foundation); and Amanda McClelland and Sydney Jones (Resolve to Save Lives).

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Vaccines have made a major contribution to the prevention and control of communicable diseases. They are considered as one of the successes in medicine and a cornerstone of public health. They have saved, and continue to save, human lives and prevent debilitating and deadly diseases, reduce illness and have improved the health and life expectancy of populations. Vaccination has led to the eradication of smallpox, and is bringing us closer than ever to the global elimination of poliomyelitis, measles and rubella. It prevents countless deaths from many other diseases such as pertussis, diphtheria, invasive Haemophilus influenzae b and meningococcal infections.

A relative of enterohemorrhagic Escherichia coli (EHEC) O157:H7, namely, sorbitol-fermenting (SF) E. coli O157:H- (nonmotile), is an important and fascinating human pathogen. The author highlights that researchers were quite motivated to find the infecting pathogen, because the PCR with primers MK1/MK2 from the enrichment culture was positive, the sorbitol MacConkey (SMAC) agar results not withstanding. Therefore, these researchers performed a colony blot hybridization test. The colonies identified with this procedure agglutinated in anti-O157 serum. Because of their ability to ferment sorbitol after overnight incubation, SF EHEC O157:H- strains cannot be distinguished from the physiological intestinal microflora using SMAC agar. This medium remains the most commonly used, rapid, and appropriate way to isolate EHEC O157:H7. At the beginning of the 1990s, researchers sought to identify virulence factors of SF EHEC O157:H- and to determine whether or not these strains were only slight phenotypic variants of non-sorbitol-fermenting (NSF) EHEC O157:H7 or if they were substantially different. They formulated an evolutionary model that includes several steps in the emergence of E. coli O157:H7. EHEC O157:H7 and SF EHEC O157:H- differ in several important aspects, including their phenotypes, the epidemiology of the infection, and the risk of the progression of the infection to hemolytic uremic syndrome (HUS).

Shiga toxin (Stx)-producing Escherichia coli (STEC) of serogroup O174 are human pathogenic intimin gene (eae)-negative STEC. To facilitate diagnosis and subtyping, we genotypically and phenotypically characterized 25 STEC O174 isolates from humans with different clinical outcomes and from animals and the environment. fliC genotyping resulted in four different genotypes (fliCH2 : n = 5; fliCH8 : n = 8; fliCH21 : n = 11; fliCH46 : n = 1). Twenty-three strains were motile expressing the corresponding H antigen; two non-motile isolates possessed fliCH8 . The stx genotypes and non-stx virulence loci, including toxins, serine-proteases and adhesins correlated well with serotypes but showed no differences with respect to the isolates' origins. Multilocus sequence typing identified seven sequence types that correlated with serotypes. Core gene typing further specified the four serotypes, including a previously unknown O174:H46 combination, and revealed distant relationships of the different serotypes within serogroup O174 and in relation to other haemolytic uremic syndrome (HUS)-associated STEC. Only serotype O174:H21 was associated with HUS. Differences in virulence factors and in the adherence capacity of STEC O174 corroborated this separation into four distinct groups. Our study provides a basis for O174 subtyping, unravels considerable genotypic and phenotypic heterogeneity and sheds light to potential environmental and animal reservoirs.

We present a summary of the main findings of the latest report of the European Food Safety Authority and European Centre for Disease Prevention and Control on zoonoses, zoonotic agents and food-borne outbreaks in the European Union (EU), based on data from 2009. Zoonoses are prevalent and widely distributed across several countries in the EU. The most important highlight of this report was the continuous decrease of human salmonellosis since 2005, probably due to effective control programmes in livestock.

A symposium was held in June 2009 near Freiburg in Germany. Twenty-nine attendees from several European countries participated, most of whom are actively involved in research and hospital infection prevention and control. The following topics were presented and discussed: isolation and screening for control of multidrug-resistant organisms; impact of the environment on healthcare-associated infection (HAI); new technologies to control infection--state of evidence; surveillance of HAI; methodological challenges and research priorities for infection control and control of HAI: learning from each other in a united Europe. This Leader summarises the main issues for debate and the number of consensus points agreed amongst delegates.

Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2–4, resourcing them realistically and devising new ways of sharing analyses.

European Union (EU) and European Economic Area (EEA) countries reported surveillance data on 2009 pandemic influenza A(H1N1) cases to the European Centre for Disease Prevention and Control (ECDC) through the Early Warning and Response System (EWRS) during the early phase of the 2009 pandemic. We describe the main epidemiological findings and their implications in respect to the second wave of the 2009 influenza pandemic. Two reporting systems were in place (aggregate and case-based) from June to September 2009 to monitor the evolution of the pandemic. The notification rate was assessed through aggregate reports. Individual data were analysed retrospectively to describe the population affected. The reporting peak of the first wave of the 2009 pandemic influenza was reached in the first week of August. Transmission was travel-related in the early stage and community transmission within EU/EEA countries was reported from June 2009. Seventy eight per cent of affected individuals were less than 30 years old. The proportions of cases with complications and underlying conditions were 3% and 7%, respectively. The most frequent underlying medical conditions were chronic lung (37%) and cardio-vascular diseases (15%). Complication and hospitalisation were both associated with underlying conditions regardless of age. The information from the first wave of the pandemic produced a basis to determine risk groups and vaccination strategies before the start of the winter wave. Public health recommendations should be guided by early capture of profiles of affected populations through monitoring of infectious diseases.

The European Community (EC) has been collecting for 15 years data on zoonoses and agents thereof that integrate the information from human cases and their occurrence in food and animals. The current data collection covers 11 zoonotic agents: Salmonella, Campylobacter, Listeria, verotoxigenic E. coli (VTEC), Yersinia spp., Brucella, Mycobacterium bovis, Trichinella and Echinoccoccus, as well as rabies and food-borne outbreaks. The European Food Safety Authority (EFSA) is assigned the tasks of examining the data collected and publishing the Community Summary Report. This Report is prepared in close collaboration with the European Centre for Disease Prevention and Control (ECDC) responsible for the surveillance of the communicable diseases in humans, and with EFSA's Zoonoses Collaboration Centre (ZCC, in the Technical University of Denmark). Member States report the data on animals, feed, food and food-borne outbreaks to EFSA's web-based reporting system and the data on the human cases are reported to ECDC's web-application for The European Surveillance System (TESSy). The flow and analysis of data are described as well as an outline of the future plans to improve the comparability of the data.

The recent detection of a novel influenza A(H1N1) virus has led to the first WHO declaration of a Public Health Event of International Concern under the International Health Regulations (IHR 2005). Here we review the early epidemiological findings of confirmed cases in Mexico, the United States, Canada and EU/EFTA countries. Strengthened surveillance and continued, transparent communication across public health agencies globally will be necessary in coming months.

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An outbreak of haemolytic uraemic syndrome (HUS) among children caused by infection with sorbitol-fermenting enterohaemorrhagic Escherichia coli O157:H- (SF EHEC O157:H-) occurred in Germany in 2002. This pathogen has caused several outbreaks so far, yet its reservoir and routes of transmission remain unknown. SF EHEC O157:H- is easily missed as most laboratory protocols target the more common sorbitol non-fermenting strains. We performed active case-finding, extensive exploratory interviews and a case-control study. Clinical and environmental samples were screened for SF EHEC O157:H- and the isolates were subtyped by pulsed-field gel electrophoresis. We identified 38 case-patients in 11 federal states. Four case-patients died during the acute phase (case-fatality ratio 11%). The case-control study could not identify a single vehicle or source. Further studies are necessary to identify the pathogen's reservoir(s). Stool samples of patients with HUS should be tested with an adequate microbiological set-up to quickly identify SF EHEC O157:H-.