Introduction Surveillance resilience has emerged as a priority topic in global health guidance, yet frameworks describing what enables surveillance systems to maintain function during disruption remain largely unexplored. A review of existing resilience frameworks identified the health systems resilience framework by Kruk et al. (2017) as the most suitable for adaptation because of its conceptual clarity. This dissertation aimed to develop a practitioner-informed resilience framework for international influenza sentinel surveillance, clarifying what enables systems to maintain function during disruption.

Methods Subject matter experts in international influenza surveillance participated in a two-part series of facilitated discussion sessions. A pilot session was conducted to refine semi-structured questions and facilitation procedures. Sessions were held virtually in English using Microsoft Teams, recorded, and transcribed. Semi-structured questions guided discussion, and participant input was captured in real time using a digital whiteboard (Miro). Discussions focused on identifying factors influencing surveillance performance during disruption and adapting the Kruk et al. resilience framework for influenza sentinel surveillance. Surveys deployed during the sessions were analyzed quantitatively, while transcripts and Miro outputs were analyzed qualitatively through a priori and inductive thematic analysis.

Results A total of 22 experts participated. Seven participated in the pilot session. Fifteen participated in the two-part facilitated discussions, of which thirteen completed both sessions. All participants reported professional experience supporting international influenza surveillance through positions held at the U.S. Centers for Disease Control and Prevention, with a few also having worked at the World Health Organization. Participants described surveillance system disruptions occurring at micro-, meso-, and macro-levels and identified factors that both enabled when present and hindered surveillance functioning when absent. Governance, leadership, and political will were most frequently emphasized by participants. The adapted framework retained all five core constructs outlined by Kruk et al. (aware, diverse, self-regulating, integrated, and adaptive) with key aims spanning operational and functional domains. Participants emphasized strong interconnectedness among constructs and noted that resilience was more system- and context-dependent than shock-dependent.

Conclusion This dissertation developed the first resilience framework specifically for international influenza sentinel surveillance and was grounded in practitioner expertise. The framework reveals surveillance resilience as multidimensional and context-dependent, with governance as a foundational consideration. Rather than serving as a scoring tool, this framework supports structured reflection and planning. Future priorities include validation with in-country practitioners, empirical testing, and development of practitioner resources while minimizing assessment burden.