Background
Coronavirus Disease 2019 (COVID-19) surveillance is essential in understanding the epidemiology and impact of this previously undescribed disease. Public health surveillance informs public health interventions and policy. We reviewed the Eastern Cape provincial COVID-19 surveillance process to determine best practices and identify opportunities to strengthen disease surveillance during public health emergencies.

Methods
We conducted a document review; content and thematic analysis of provincial COVID-19 surveillance guidelines, tools, and surveillance reports compiled between March 2020 and November 2021. This was augmented by reviewing surveillance-related findings of the facilitator-led, key-informant discussions undertaken during the 2021 provincial COVID-19 Intra-Action Review.

Results
Four themes identified included surveillance process description and human, technical, and technological resources for COVID-19 surveillance. Local surveillance networks, established pre-COVID-19, aided COVID-19 case detection and reporting. Minimal data elements required for case reporting promoted timeous information relay. Poor data quality hindered public health response. Under-utilization of the electronic platform of the routine provincial surveillance system limited the availability of enriched COVID-19 data. A combination of poor internet connectivity, multiple surveillance information pathways, and vertical and non-automated management of surveillance data resulted in data disharmony and data linking challenges. COVID-19 preparedness training, technical and human resources and support were provided to strengthen an under-resourced district surveillance function. Inadequate follow-up training for evolving COVID-19 surveillance tools and processes was reported.

Conclusion
Context-specific technical guidelines that map surveillance information flow, establish standardized data management processes and specify surveillance and data quality indicators should be developed and disseminated to surveillance teams. Revisions of guidelines and tools should be preceded by adequate training and support. Investing in human resources for surveillance and information and communication technology infrastructure develops robust, integrated, routine surveillance systems that can be adapted for use in diverse health emergencies. Reviewing the COVID-19 surveillance process identified strengths and opportunities to improve public health surveillance and response.