General discussion 9 287 9.3.2 Surveillance data: a global perspective Focussing on the Dutch perspective alone will only partly help the Netherlands equip itself to face future disease outbreaks. Modelling studies have demonstrated that spillover events of zoonotic pathogens are likely to occur in (sub-)tropical regions[109]. Supporting countries within this high-risk spill-over zone in collecting and interpreting data for early detection of outbreaks, and for use in epidemiological research, requires a wholly collaborative approach between countries, including the Netherlands. For instance, throughout the pandemic, the laboratory infrastructure and human and financial resources required for PCR testing has been prohibitive for many LMICs aiming to expand access to testing within a limited healthcare budget and many competing disease burdens. However, PCR testing continues to play an important role in monitoring SARS-CoV-2 transmission and for detecting potential new variants. As such, investments should be made to support wider access to diagnostics[110] and explore how genomic surveillance can be optimised in the context of countries with low testing rates[110]. In Curaçao, for example, a small island developing state (SIDS), a proof-of-concept existed from previous surveillance by primary care physicians of febrile illnesses, for whom a small proportion were tested for vector-borne diseases[111]. When the government ceased to subsidise SARS-CoV-2 PCR testing from 5 June 2022 onwards, testing rates dropped. In response, the public health department relied upon syndromic surveillance of respiratory illnesses in combination with once-weekly PCR-testing of a random sample of individuals with the added possibility for sequencing. Introduction of this approach at an earlier stage in the pandemic could have allowed for more efficient allocation of available resources. It is crucial that LMICs are supported in setting up resource-efficient methods of surveillance and that efforts continue to be made to expand access to diagnostics. In this way, data required for both acute decision-making and research can be made more readily available. 9.3.3 Challenges in long COVID outcome definition, study design and data analysis Although long COVID research has been identified as a research priority, it is a complex topic to investigate. In this final section of the general discussion, I will outline some of the methodological problems faced in investigating this novel condition.
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