Required Elements for an Integrated Biosurveillance Platform: A Capacity and Needs Assessment of the Central Government in the Republic of Korea

Abstract

New and reemerging infectious disease outbreaks threaten human safety worldwide, increasing the urgency to implement biosurveillance systems that enhance government capacity in public health emergency preparedness and response. To do so, it is necessary to evaluate existing surveillance and response activities and identify potential barriers at the national level. This study aimed to assess the current status and readiness of government agencies in South Korea, particularly for information sharing and use, and to identify barriers and opportunities in developing an agency-integrated biosurveillance system. The target sample size was 66 government officials, working at 6 relevant government ministries. We invited a total of 100 officials to participate. A total of 34 government officials completed the survey (34.0% response rate), 18 (52.9%) of whom were affiliated with the Korea Disease Control and Prevention Agency or the Ministry of Health and Welfare. Findings revealed that information sharing between government agencies occurred frequently, but a discrepancy existed in terms of the type of information shared and stored. Although information sharing with other agencies and ministries occurred at all stages—prevention, preparation, response, and recovery—it mostly revolved around preventive activities, with no respondents reportedly sharing recovery-related information. An agency-integrated biosurveillance system is crucial in preparing for the next pandemic, as well as supporting information sharing, analysis, and interpretation across humans, animals, and the environment. It is key to national and global health security.

Introduction

Since the 2000s, new and reemerging infectious diseases have been rapidly increasing, spreading worldwide in a short period and causing tremendous human, social, and economic losses.¹ Disease outbreaks threaten human safety worldwide across jurisdictional boundaries. The COVID-19 pandemic has become a major global health concern and has reinforced the importance of biosurveillance to enhance the capacity of government sectors to prepare for and respond to public health emergencies. The term biosurveillance refers to the systematic collection, integration, and interpretation of essential information on the activities of all hazards and diseases that can harm humans, animals, and the environment.² Data collected for biosurveillance systems thus includes data related to humans, animals (eg, livestock and wild animals), and the environment (eg, climate, pollution). Unlike traditional surveillance, which focuses on pathogen identification and specific disease ecologies, the emphasis of biosurveillance is on situational awareness and prompt decisionmaking through the exchange and integration of relevant information from various sources.³

The purpose of the biosurveillance system is to share timely and actionable information with public health officials and leaders at the local, national, and global levels; information sharing is therefore the core component of a biosurveillance system. For instance, during the COVID-19 pandemic in the Republic of Korea, new digital and information technology tools such as smartphone GPS and credit card transactions enabled responders and decision makers to obtain vital and timely information for digital contact tracing and investigation in the biosurveillance system.⁴ The use of such biosurveillance tools reflects the needs and demands of users and organizations. It also strengthens efficiencies in coordination among relevant ministries and agencies through automated data collection, analysis tools, and alert reporting.⁵

In the Republic of Korea, failure to respond to the 2015 Middle East respiratory syndrome (MERS) outbreak reshaped the landscape of the public health surveillance system, and the perceived importance of implementing a national biosurveillance system was higher than ever.⁶ Based on lessons learned, the government amended the Infectious Disease Control and Prevention Act in 2015 to specify the roles and responsibilities of the central and local governments in disease control measures. Furthermore, risk communication to the public was mandated by law, and networks among key actors were strengthened following the MERS outbreak. Major revisions to the biosurveillance system, facilitated by the MERS outbreak, led to the integration of previously scattered data on human and animal health among government agencies using information technology and digital technology.⁴

Despite growing recognition of the importance of biosurveillance and efforts to implement an effective biosurveillance system, the system in the Republic of Korea still needs to be strengthened. One study found notable limitations in the effectiveness of the Infectious Disease Prevention and Control Act of Korea to protect public health by analyzing the country's current infectious disease surveillance system by comparing it with the World Health Organization International Health Regulations (2005)⁷ and US biosurveillance-related legislation.⁸ The Act does not address the need for data integration and lacks guidance on detection and monitoring of disease, integration of information and systems, and joint surveillance.⁸ Lack of a legal and organizational basis for these issues may delay prompt decisionmaking during a public health emergency.

Countries with advanced biosurveillance systems have assessed and documented the capabilities required for a national biosurveillance system.^9,10 To our knowledge, however, no study has examined the current status and competencies in cross-agency sharing of information in the Republic of Korea. The goal of biosurveillance is situational awareness and timely response by sharing and integrating data collected from relevant agencies and disciplines, and therefore assessing current capacity is crucial for identifying potential barriers and challenges. Some countries lack systems or resources at the initial stage of biosurveillance development. The needs and capacity of biosurveillance components assessed in this study can provide insights, systematic understanding, and recommendations for those countries.

This study aimed to assess the capacity required for implementing an agency-integrated biosurveillance system through interviews with those who work in government agencies related to infectious disease response in the Republic of Korea. The 3 domains of assessment were (1) types and means of shared data or information, (2) the level of preparation or competencies for data sharing and utilization, and (3) perceived factors for a successful agency-integrated biosurveillance system. It is important to note that this study was conducted before the COVID-19 pandemic.

Methods

Respondents

Study respondents were selected from government agencies responsible for managing the health of humans, animals, plants, or the environment. Two research team members reviewed the roles and responsibilities of each division in the selected agencies. Divisions with roles and responsibilities related to biosurveillance activities—collection, integration, and interpretation of information that can impact human, animal, or environment health—were considered eligible for the study. As of August 1, 2019, the date when respondents were selected, the total number of staff working in the selected agencies was 656, and the sample size of the study was aimed at 10% (n = 66) of the total population. Respondents were selected using convenience sampling, which is dependent on availability and willingness to participate. The agencies—such as the Ministry of Health and Welfare (MOHW) and the Korea Disease Control and Prevention Agency (KDCA), formerly the Korea Centers for Disease Control and Prevention—and divisions, along with the number of staff, are presented in Table 1.

Table 1.

Number of Eligible Agency and Division Staff Participating in the Survey

Agencies (Number of Selected Divisions)	Divisions^a	Total Staff^a n	Invited n	Completed Survey n (%)
KCDC (11) and MOHW (1)	KDCA: Division of Strategic Planning for Emerging Infectious Diseases, Division of Quarantine Support, Division of Public Health Emergency Management, Division of Risk Assessment and International Cooperation, Division of Emerging Infectious Disease Response, Division of Infectious Disease Control, Division of Zoonotic and Vector Borne Disease Control, Division of Laboratory Diagnosis Management, Division of Healthcare Associated Infection Control, Division of Vectors and Parasitic Diseases, Division of High-Risk Pathogen Research MOHW: Division of Disease Control Policy	227	38	18 (47.4)
DSMO (2)	Public Health Disaster Response Division, Societal Disaster Response Policy Division	20	7	3 (42.9)
APQA (5) and MAFRA (2)	APQA: Animal Disease Control Division, Animal Quarantine Division, Veterinary Epidemiology Division, Animal Disease Diagnostic Division, Import Risk Assessment Division MAFRA: Animal Health Policy Division, Avian Influenza and Small Animal Health Control Division	112	19	2 (10.5)
NIFDS (4) and MFDS (3)	NIFDS: Food Safety Risk Assessment Division, Food Microbiology Division, New Hazardous Substances Division, Toxicological Research Division MFDS: Imported Food Inspection Division, Agro-Fishery Products Safety Policy Division, Pharmaceutical Policy Division	180	19	6 (31.6)
NIER (3) and MOE (1)	NIER: Environmental Health Research Division, Biosafety Research Team, Risk Assessment Division MOE: Biodiversity Division	100	14	3 (21.4)
AFMRI (1), AFMC (1), and MOD (1)	AFMRI: Office of the Director AFMC: Infection Control Office MOD: Health Policy Division	17	3	2 (66.7)
Total	35 divisions	656	100	34 (34.0)

As of August 2, 2019. Abbreviations: AFMC, The Armed Forces Medical Command; AFMRI, Armed Forces Medical Research Institute; APQA, Animal and Plant Quarantine Agency; DSMO, Disaster Safety Management Office; KDCA, Korea Disease Control and Prevention Agency; MAFRA, Ministry of Agriculture, Food and Rural Affairs; MFDS, Ministry of Food and Drug Safety; MOD, Ministry of Defense; MOE, Ministry of Environment; MOHW, Ministry of Health and Welfare; NIER, National Institute of Environmental Research; NIFDS, National Institute of Food and Drug Safety Evaluation.

Development of Capacity and Needs Assessment Survey

After a review of the leading literature, including the National Biosurveillance Science and Technology Roadmap,¹¹ WHO International Health Regulations (2005),⁷ and WHO Joint External Evaluation tool,¹² the research team developed a survey instrument. The survey consisted of 4 domains: (1) data and information, (2) the level of preparation for data sharing and utilization, (3) required support for using the biosurveillance system, and (4) general characteristics of the study respondents. The survey was pilot tested by 2 officials from the KDCA and 1 from the Ministry of Food and Drug Safety. The final survey included 30 questions; the content covered by the questions are presented in Table 2. To make a comparison between government agencies, we aimed to measure core and overall competencies rather than specific ones.

Table 2.

Domains and Content of the Capacity and Needs Assessment Survey

Domain	Content	Number of questions
Shared data and information	Experience in sharing information with other government agencies (purpose, data types, sharing methods)	1
Level of preparation for data sharing and use	Surveillance (surveillance system and organizations; priority diseases, conditions, syndromes)	2
	Reporting (official reporting systems; reporting periods; elements of a report)	3
	Data management and analysis (electronic tools for data management; analysis by person, place, and time)	2
	Assessment (conducting risk assessments)	1
	Human resources (workforce structure; training and education)	2
	Preparedness (response plan; risk factor detection)	2
	Response (emergency response operations; rapid response team; emergency response plans)	3
	Risk communication (risk communication plans and guidelines)	1
	Laboratory system (laboratory capacity; specimen collection, referral, and transport; laboratory quality and safety system)	3
Required support for using the biosurveillance system	Governance	1
	Expected impacts (required functions)	2
	Conditions for the effective operation	1
	Experience of collaboration with other government agencies, levels of collaboration (networking, cooperating, coordinating, collaborating), barriers to collaboration	1
General characteristics	Age, sex, affiliated organization, division and position, job description, years worked	5
Total		30

Data Collection and Analysis Procedures

A manager of the selected division and several mid-level staff (at least 1 but no more than 4) were chosen based on their job descriptions provided on the websites. We contacted the potential study respondents by telephone or email, using the contact information provided on the websites of each agency. Because the Animal and Plant Quarantine Agency provided only email information, we approached staff members at that agency by email first. We sent 100 invitations (89 by telephone and 11 by email) with a brief statement about the purpose and content of the survey. Those who agreed to participate were asked to complete a self-reported survey tool designed using an online survey platform (Qualtrics, Provo, UT). Both telephone and email reminders were sent every week for 3 weeks for those who had not responded. The frequency or average of the collected responses was calculated, and only selected parts of the survey results are presented and discussed in this article. The results were presented in 2 groups (KDCA and MOHW vs other agencies), according to whether the agency's primary mission is dedicated to improving public health. This study was approved by the Seoul National University Institutional Review Board (No.1909/002-004).

Results

Respondent Characteristics

A total of 34 respondents completed the online survey. Response rates for each agency are provided in Table 1. Table 3 shows that the majority of respondents were experts in natural science (n = 12, 35.3%), followed by public health, medicine, or nursing (n = 10, 29.4%), and veterinary science (n = 4, 11.8%). Of the 34 respondents, those affiliated with the KDCA and the MOHW accounted for more than half (n = 18, 52.9%), followed by the Korea Food and Drug Administration and the Ministry of Food and Drug Safety (n = 6, 17.6%). The most frequently reported roles and responsibilities were disease surveillance (n = 8, 23.5%), data collection and risk assessment (n = 6, 17.6%), and performing diagnostic experiments (n = 4, 11.8%). Other responsibilities included diagnosis and management of infectious diseases, epidemiologic investigation for diseases, establishing safety standards for human exposure, and organization operation.

Table 3.

Characteristics of Respondents by Agency Group

Characteristics	KDCA and MOHW (n = 18)	Others (n = 16)	Total (N = 34)
Characteristics	n (%)	n (%)	n (%)
Academic majors
Natural science	6 (33.3)	6 (37.5)	12 (35.3)
Public health, medicine, nursing	8 (44.4)	2 (12.5)	10 (29.4)
Veterinary medicine	0 (0.0)	4 (25.0)	4 (11.8)
Public administration	0 (0.0)	2 (12.5)	2 (5.9)
Engineering	1 (5.6)	1 (6.3)	2 (5.9)
Humanities and social sciences	1 (5.6)	0 (0.0)	1 (2.9)
Others	2 (11.1)	1 (6.3)	3 (8.8)
Affiliations
KDCA and MOHW	18 (100.0)	–	18 (52.9)
NIFDS and MFDS	–	6 (37.5)	6 (17.6)
DSMO	–	3 (18.8)	3 (8.8)
NIER and MOE	–	3 (18.8)	3 (8.8)
AFMRI, AFMC, and MOD	–	2 (12.5)	2 (5.9)
APQA and MAFRA	–	2 (12.5)	2 (5.9)
Main roles and responsibilities
Disease surveillance	5 (27.8)	3 (18.8)	8 (23.5)
Data collection and risk assessment	4 (22.2)	2 (12.5)	6 (17.7)
Diagnostic experiments	3 (16.7)	1 (6.3)	4 (11.8)
Disease quarantine and control	1 (5.6)	1 (6.3)	2 (5.9)
Information system development and operation	1 (5.6)	0 (0.0)	1 (2.9)
Others	9 (50.0)	4 (25.0)	13 (38.2)

Abbreviations: AFMC, Armed Forces Medical Command; AFMRI, Armed Forces Medical Research Institute; APQA, Animal and Plant Quarantine Agency; DSMO, Disaster Safety Management Office; KDCA, Korea Disease Control and Prevention Agency, formerly Korea Centers for Disease Control and Prevention; MAFRA, Ministry of Agriculture, Food and Rural Affairs; MFDS, Ministry of Food and Drug Safety; MOD, Ministry of Defense; MOE, Ministry of Environment; MOHW, Ministry of Health and Welfare; NIER, National Institute of Environmental Research; NIFDS, National Institute of Food and Drug Safety Evaluation.

Experiences of Information Sharing

A total of 25 (73.5%) respondents reported that they had experience sharing information with other government agencies in the past 12 months (Table 4). Of these respondents, experiences in information sharing within the previous 12 months were similar between the KDCA and MOHW (n = 13, 52.0%) and other agencies (n = 12, 48.0%). Among the purposes listed for information sharing (prevention, preparedness, response, and recovery), the most common purpose was prevention (n = 9, 36%) and the least common purpose was recovery (n = 0). The purposes reported for information sharing differed by agency groups. The most common purpose reported by the 13 respondents from the KDCA and MOHW was preparedness (n = 5, 38.5%), while the 12 respondents from other agencies most commonly shared information related to prevention (n = 7, 58.3%). The information shared in preparedness-related activities included current response plans/manuals and available resources for crisis management. The information shared in prevention-related activities—such as risk analysis, risk mapping, and reviewing the contents of the relevant law—is related to the risk factors of events and population vulnerability.

Table 4.

Experiences Regarding Information Sharing Among Respondents

Characteristics	KDCA and MOHW (n = 18)	Others (n = 16)	Total (N = 34)
Characteristics	n (%)	n (%)	n (%)
Experience sharing information within the past 12 months
None	5 (27.8)	4 (25.5)	9 (26.5)
Within a week	3 (16.7)	7 (43.8)	10 (29.4)
Within a month	6 (33.3)	3 (18.8)	9 (26.5)
Within 6 months	2 (11.1)	1 (6.3)	3 (8.8)
Within 12 months	2 (11.1)	1 (6.3)	3 (8.8)
Purposes of sharing information^a
Prevention	2 (11.1)	7 (43.8)	9 (26.5)
Preparedness	5 (27.8)	2 (12.5)	7 (20.6)
Response	3 (16.7)	2 (12.5)	5 (14.7)
Recovery	0 (0.0)	0 (0.0)	0 (0.0)
Others	3 (16.7)	1 (6.3)	4 (11.8)
Types of information shared^a,b
Official reports	9 (50.0)	9 (56.3)	18 (52.9)
Laboratory data	2 (11.1)	3 (18.8)	5 (14.7)
Notification data (clinic or healthcare center)	0 (0.0)	1 (6.3)	1 (2.9)
Helpline data	0 (0.0)	1 (6.3)	1 (2.9)
Others	3 (16.7)	1 (6.3)	4 (11.8)
Means of sharing information^a,b
Email	9 (50.0)	3 (18.8)	12 (35.3)
Written forms of official documents	7 (38.9)	3 (18.8)	10 (29.4)
Telephone	4 (22.2)	6 (37.5)	10 (29.4)
Text messages	1 (5.6)	2 (12.5)	3 (8.8)
Others	1 (5.6)	6 (37.5)	7 (20.6)

Only the 25 people who responded that they had experience to the first statement provided answers to this statement. ^bMultiple responses allowed. Percentages were calculated using the total number of respondents in each column as the denominator. Abbreviations: KDCA, Korea Disease Control and Prevention Agency, formerly Korea Centers for Disease Control and Prevention; MOHW, Ministry of Health and Welfare.

The most frequently shared type of information with other government agencies was official reports (n = 18, 72.0%), which included daily or weekly national and international disease outbreak trend reports and annual epidemiology surveys or reports. Use of this type of communication was reported by 9 (69.2%) of the 13 respondents from the KCDC and MOHW and 9 (75.0%) of the 12 respondents from other agencies. The primary means of sharing information, however, differed by agency groups, with the majority of 13 respondents from KDCA and MOHW preferring written forms such as email (n = 9, 69.2%) and written forms of official documents (n = 7, 53.8%), whereas the 12 respondents from other agencies preferred more human interaction, such as telephone communication (n = 6, 50.0%). Respondents from other agencies also reported that meetings were frequently used to share information.

Capacity for Information Sharing and Use

The capacity for information sharing and use was assessed in terms of risks or crises in surveillance systems, response systems, human resources, and risk communications (Table 5). Most (n = 31, 91.2%) of the 34 respondents reported their agency had a designated organization or department to monitor, evaluate, and respond to crises. A total of 17 (94.4%) of the 18 respondents from the KDCA and MOHW group reported having an organization or department to monitor, evaluate, and respond to crises, while 14 (87.5%) of the 16 respondents from the other agencies group reported having such an organization or department. Those without a designated organization provided guidelines for monitoring, evaluating, and responding to crises. More than half of the 34 respondents reported documenting priority cases and events (n = 20, 58.8%). This contrasts with those who reported having baseline data for all priority cases and events (n = 11, 32.4%) or those with only baseline data for some priority cases and events (n = 8, 23.0%). The priority cases included African swine fever, emerging infectious diseases, zoonotic diseases, and heat illness.

Table 5.

Agency Capacity for Information Sharing and Use as Reported by Respondents

Capacity	KDCA and MOHW (n = 18)	Others (n = 16)	Total (N = 34)
Capacity	n (%)	n (%)	n (%)
Surveillance system
Designated organization or department to monitor, evaluate, and respond to crises
Yes	17 (94.4)	14 (87.5)	31 (91.2)
No	0 (0.0)	2 (12.5)	2 (5.9)
Do not know	1 (5.6)	0 (0.0)	1 (2.9)
Documentation of priority cases and events	11 (61.1)	9 (56.3)	20 (58.8)
Baseline data for priority cases and events^a
Present for all cases and events	6 (33.3)	5 (31.3)	11 (32.4)
Present for some cases and events	4 (22.2)	4 (25.0)	8 (23.5)
No baseline data	1 (5.6)	0 (0.0)	1 (2.9)
Data collected to monitor priority events^a
Reports from international organizations or national health agencies	8 (44.4)	5 (31.3)	13 (38.2)
Specific disease surveillance systems	7 (38.9)	6 (37.5)	13 (38.2)
Press releases	5 (27.8)	5 (31.3)	10 (29.4)
Notification data (clinic/healthcare center)	8 (44.4)	1 (6.3)	9 (26.5)
Laboratory data	4 (22.2)	5 (31.3)	9 (26.5)
Others	2 (11.1)	1 (6.3)	3 (8.8)
Response system
Response plan to the public health crisis
Yes	15 (83.3)	12 (75.0)	27 (79.4)
No	0 (0.0)	1 (6.3)	1 (2.9)
Do not know	3 (16.7)	3 (18.8)	6 (17.7)
Regular revision of response plan^b	15 (83.3)	11 (68.8)	26 (76.5)
Operation center to monitor and coordinate crises or events
Yes	17 (94.4)	12 (75.0)	29 (85.3)
No	1 (5.6)	3 (18.8)	4 (11.8)
Do not know	0 (0.0)	1 (6.3)	1 (2.9)
Emergency response or rapid response team composition^c
Epidemiologists	18 (100.0)	3 (18.8)	21 (61.8)
Quarantine officers	16 (88.9)	3 (18.8)	19 (55.9)
Experimental analysts	13 (72.2)	6 (37.5)	19 (55.9)
Risk communication professionals	12 (66.7)	3 (18.8)	15 (44.1)
Private professionals	10 (55.6)	1 (6.3)	11 (12.4)
Others	3 (16.7)	1 (6.3)	3 (8.8)
Human resources
Staff composition within the division^c
Public health	15 (83.3)	9 (56.3)	24 (70.6)
Veterinary medicine	8 (44.4)	14 (87.5)	22 (64.7)
Experimental analysis	6 (33.3)	8 (50.0)	14 (41.2)
Medicine	8 (44.4)	2 (12.5)	10 (29.4)
Risk communication	2 (11.1)	2 (12.5)	4 (11.8)
None of the above	1 (5.6)	2 (12.5)	3 (8.8)
Experience of education or training in the last 12 months	8 (44.4)	9 (56.3)	17 (50.0)
Risk communication
Guidelines for risk communication	14 (77.8)	12 (75.0)	26 (76.5)
Means for risk communication^c
Media interview, briefings, press releases	17 (94.4)	14 (87.5)	31 (91.2)
Web page	14 (77.8)	7 (43.8)	21 (61.8)
Social media	12 (66.7)	2 (12.5)	14 (41.2)
Emergency alert system (emergency alert texts)	5 (27.8)	3 (18.8)	8 (23.5)
Others	2 (11.1)	2 (12.5)	4 (11.8)

Only those who indicated that they documented priority cases and events provided answers to this statement. ^b Only those who indicated that they had a response plan provided answers to this statement. ^c Multiple responses allowed. Percentages were calculated using the total number of respondents in each column as the denominator. Abbreviations: KDCA, Korea Disease Control and Prevention Agency, formerly Korea Centers for Disease Control and Prevention; MOHW, Ministry of Health and Welfare.

The most common data collected to monitor priority events were announcements or reports from international organizations or national health agencies (n = 13, 38.2%), specific disease surveillance systems (n = 13, 38.2%), and press releases (n = 10, 29.4%). About 38.2% (n = 13) reported having official reporting formats for all priority cases, whereas 14.7% (n = 5) responded only for some priority cases. The most frequently used reporting format was the infectious disease outbreak reporting and the internal electronic document system used in the agency.

The majority (n = 27, 79.4%) of the 34 total respondents reported that their department had a response plan to the public health crisis and that the plans were regularly reviewed through simulation training or sharing the experiences. Of those respondents, the most frequently reported elements of the response plan included cooperating with other agencies or departments (n = 25, 92.6%), designating the coordination and responsible organization (eg, emergency operation center) (n = 25, 92.6%), and data collection and dissemination system (n = 24, 88.9%). A greater majority (n = 29, 85.3%) of the 34 respondents reported that their agency had some type of operation center (eg, leadership, communication, management) to coordinate and monitor emergency crises or events. However, only 12 (75.0%) of the 16 respondents from other agencies reported the establishment of operation centers compared with 17 (94.4%) of the 18 respondents from KDCA and MOHW. The composition of emergency response teams varied, but usually included field epidemiologists, quarantine officers, and surveillance analysts.

In terms of staff composition, the 34 respondents reported their division included staff trained in public health (n = 24, 70.6%), veterinary medicine (n = 22, 64.7%), and experimental analysis (n = 14, 41.2%). In addition, half (n = 17) of those surveyed have received training in health-related information processing during the past 12 months such as data collection, management, utilization, and interpretation. The training included a field epidemiology training program, education related to One Health, and laboratory management. The average training time over 12 months was 12.9 hours.

Most reported the presence of manuals or guidelines for the disclosure of information related to risks or crises (n = 26, 76.5%). Media interviews, briefings, or press releases (n = 31, 91.2%) were the most frequently used means of communication when the agency disclosed information about risks or crises, followed by web pages (n = 21, 61.8%) and social media (n = 14, 41.2%). Means for risk communication were not materially different between the agency groups.

Enabling Factors for a Successful Agency-Integrated Biosurveillance System

Upon the establishment of the agency-integrated biosurveillance system, most (n = 26, 76.5%) respondents thought that the KDCA and MOHW should be the main body of management (Table 6). Only 66.7% (n = 12) of the 18 respondents in the KDCA and MOHW group felt that their organization should be the main body of management compared with 87.5% (n = 14) respondents from the other agencies group. The primary reason for preferring the KDCA and MOHW was its expertise in responding to the current public health crisis. Those who chose the Ministry of Interior and Safety to be the main body of management indicated that it was for the ease of coordination between agencies and ministries. Many respondents expected an integrated biosurveillance system to serve as a communication channel between agencies (n = 16, 47.1%), while others thought it could provide data analysis (n = 11, 32.4%), diverse data (n = 4, 11.8%), modeling and prediction results (n = 3, 8.8%). Enabling factors for the successful operation of the integrated biosurveillance system were reported to be legislation to collect information (n = 25, 73.5%), workforce availability and support for technology development, program management, and training (n = 21, 61.8%), and securing long-term financial support (n = 19, 55.9%). Other reported factors in establishing a successful system were increasing the awareness of the biosurveillance integration, defining the scope of shared information, and expanding the field area. Enabling factors were generally similar between the agency groups. Yet, perceived importance was found to be different between the agency groups for system maintenance and operation (n = 8, 44.4% among the 18 KDCA and MOHW respondents vs n = 3, 18.8% among the 16 other respondents).

Table 6.

Perceived Enabling Factors in Establishing a Successful Agency-Integrated Biosurveillance System as Reported by Respondents

Variables	KDCA and MOHW (n = 18)	Others (n = 16)	Total (N = 34)
Variables	n (%)	n (%)	n (%)
Main body of management
KDCA and MOHW	12 (66.7)	14 (87.5)	26 (76.5)
MOIS	5 (27.8)	1 (6.3)	6 (17.7)
MSIT	0 (0.0)	1 (6.3)	1 (2.9)
Others	1 (5.6)	0 (0.0)	1 (2.9)
Expected function of the biosurveillance platform
Communication channel between agencies	7 (38.9)	9 (56.3)	16 (47.1)
Provision of analysis results for the collected data	6 (33.3)	5 (31.3)	11 (32.4)
Provision of diverse information	3 (16.7)	1 (6.3)	4 (11.8)
Provision of modeling and prediction results	2 (11.1)	1 (6.3)	3 (8.8)
Enablers for the successful operation of the platform^a
Legislation to collect information	14 (77.8)	11 (68.8)	25 (73.5)
Human resources for technology development, program management, and education	12 (66.7)	9 (56.3)	21 (61.8)
Long-term financial support	10 (55.6)	9 (56.3)	19 (55.9)
System maintenance	6 (33.4)	9 (56.3)	15 (44.1)
Establishment of a reporting system	9 (50.0)	7 (43.8)	16 (47.1)
Operation (system reliability, efficiency, and preparedness)	8 (44.4)	3 (18.8)	11 (32.4)
User-friendly hardware	5 (27.8)	3 (18.8)	8 (23.5)
Education and training for using the system	3 (16.7)	3 (18.8)	6 (17.6)
Marketing targeted at healthcare providers, governments, and general users	2 (11.1)	1 (6.3)	3 (8.8)

Multiple responses allowed. Percentages were calculated using the total number of respondents in each column as the denominator.

Abbreviations: KDCA, Korea Disease Control and Prevention Agency; MOHW, Ministry of Health and Welfare. MOIS, Ministry of Interior and Safety; MSIT, Ministry of Science and Information and Communications Technology

Discussion

This study aimed to assess the capacity and needs for implementing an agency-integrated biosurveillance system by administering a survey to those who work at divisions related to infectious disease response at relevant government agencies in the Republic of Korea. The capacity for biosurveillance was generally high among the respondents, as the majority had experiences of information sharing, and had a system to monitor, evaluate, and respond to crises. The capacity and needs were generally similar between the agency groups (KDCA and MOHW vs other agencies). Yet, stronger capacity levels regarding a response system (eg, response plan, emergency operation center) were found among the KDCA and MOHW group. For both groups, the anticipated main function of a biosurveillance platform was a communication channel between agencies. Empirical findings from the study respondents—a total of 34 government official respondents who worked in infectious disease response units at 6 relevant government ministries in the Republic of Korea—demonstrated that while information sharing between government agencies occurred frequently, a discrepancy existed in terms of information sharing and storing. For instance, although the consensus was evident for information sharing with other agencies and ministries at all stages (prevention, preparation, response, and recovery), it mostly revolved around preventive activities, with no respondents reportedly sharing recovery-related information.

Of the government agencies collecting data, only some reported computerizing the data, resulting in great inefficiency. While written forms of communication, including email and official documents, are conventional means of sharing information, the associated limitations with those channels should be considered, such as the inability to verify how data are used and inefficiency in information sharing when the data provider is absent/changed. This issue is critical because emergency cases must be reported immediately to the related government agencies, and the current means of information sharing may fail to identify situational awareness and respond to the crisis.

When developing the agency-integrated biosurveillance system, most (n = 26, 76.5%) respondents believed the KDCA and MOHW should be the body of governance due to its expertise in responding to public health crises. Implementing and enforcing laws and regulations to support financial and human resources and imposing privacy-related regulations and exemptions are crucial features for strong policy impetus and securing organizational independence. In addition to laws and policies, human resources and long-term financial support were considered key enablers for the successful operation of the biosurveillance platform. Similarly, monetary and human resources were considered high priority in a survey of 500 local health departments in the United States.⁹ The main functions of the integrated biosurveillance system should include the following: (1) enactment of laws and regulations; (2) frequent communication and split responsibilities among agencies; (3) consistent or automated data collection, monitoring, analysis, and evaluation of potential risk (eg, setting thresholds); and (4) support for necessary research.¹³ These functions, in return, can improve the efficiency of work coordination between relevant ministries and reduce the burden of the workload.¹⁴

Finally, it is necessary to train professionals on the agency-integrated biosurveillance system. Although more than 95% of respondents worked in public health, medicine, and veterinary medicine, only half had training experience in the interface of humans, animals, and environment. Existing curricula regarding biosurveillance and One Health should be expanded and emphasized for future generations of public health professionals and to meet the criteria of 1 epidemiologist per 200,000 population. Ongoing conversations engaging multiple disciplines and experts—including doctors, veterinarians, environmental scientists, law and institutional experts, policymakers, administrators, economists, and architects—would also be beneficial. This effort would highlight and promote the importance of biosurveillance, not limited to human health, but also animals and the environment.

This study had several limitations. First, the size of the final study population did not meet our goal, and we received a varied response rate by the agency (lowest 11% to highest 67%). The response rates were lower among agencies dealing with nonhuman subjects (eg, animals, environment). We aimed to collect data from 66 respondents, however, only 34 participated. Because an efficient agency-integrated biosurveillance system can improve the information sharing and use and reduce workload burden, future studies should include additional assessment surveys for government agencies with low response rates. More than half of the respondents were from KDCA and MOHW, and therefore other agencies might regard the issue of biosurveillance as being limited to humans and assume the study was beyond their scope.¹⁵ Another limitation regarding the sample is that we used a convenience sampling technique. Thus, it is more likely those who were more interested and willing to engage in biosurveillance systems chose to participate in the survey. Using other sampling techniques to ensure sample representativeness could provide results showing lower levels of needs and capacity than that of our results. Despite the limited statistical power due to convenience sampling, the results allowed us to examine how the various agencies interact with other partner organizations and agencies. The information-sharing experience may have been underreported because certain information is routinely transferred through a systemic channel and therefore shared with only seasoned officers. Furthermore, our modes of first contact (email vs telephone) about participating in the survey differed by agency. Those in the Animal and Plant Quarantine Agency were first contacted by email while others were contacted by telephone. Different modes of contact may have resulted in different response rates. However, because reminders for participation were sent by both telephone and email, the impact of the first contact mode on the response rate would have been small. It is important to note that because the study was conducted before the COVID-19 pandemic, future studies should assess changes in the surveyed element during the pandemic.

Regardless of the limitations, our research demonstrated that relevant government agencies urgently need to understand the concept of biosurveillance and reach a consensus on establishing agency-integrated biosurveillance systems. Because different views and opinions between agencies are challenging issues in cooperation, future studies on investigating the causes of disagreements are necessary.¹⁶ The implementation sciences community should continue to investigate existing challenges in biosurveillance, such as gaps between theory and practice, as well as delve into different ways of sharing information to improve the biosurveillance system. For countries seeking to advance biosurveillance systems, identifying the capacity and needs of the system would be the initial step. Then, strengthening the identified enabling factors (in the case of Korea, legislation, finance, and staff resources) should be the next step. The assessed needs and capacity within the national context are the fundamental basis of legislation and regulation. The current study findings can inform countries in similar settings by providing core components and key processes.

Conclusion

Because the majority of respondents indicated handling national or international emergencies over the previous 24 months, even before the COVID-19 pandemic, we expect the need for a coordinated response to public health emergencies to increase in the future. To better prepare for and respond to the next infectious disease outbreak, an agency-integrated biosurveillance system is crucial because it supports information sharing, analysis, and interpretation across humans, animals, and the environment all in one place. An agency-integrated biosurveillance system is in line with the notion of One Health, and both are contingent upon a strong commitment to collaboration across disciplines and government sectors and are key to national and global health security.

Footnotes

Acknowledgments

We gratefully appreciate government officials for their participation and sharing their experiences with us. We also extend our thanks to our research team for their support. This research was supported by Government-wide R&D Fund project for infectious disease research (GFID), Republic of Korea (grant number: HG18C0091).

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