surveillance as

applied to public
health
 Infectious diseases
surveillance designs
 Traditional disease notification
 Outbreak investigation
 Cluster investigation
 Enhanced surveillance
 Sentinel surveillance
 Emerging infectious diseases
 diagnosis-based surveillance
 syndromic surveillance
 Molecular biology and surveillance
Definition
“Surveillance, when applied to a disease, means
 the continued watchfulness over the distribution and trends
of incidence
 through the systematic collection, consolidation and
evaluation of morbidity and mortality reports and other
relevant data.
 Intrinsic in the concept is the regular dissemination of the
basic data and interpretation to all who have contributed
and to all others who need to know.
 The concept, however, does not encompass direct
responsibility for control activities.”
A.D. Langmuir, 1963
COMMUNICABLE DISEASE
SURVEILLANCE or RESEARCH?
 Ongoing  Time-limited
 Generates hypotheses  Tests hypotheses
 Incomplete data on  Complete data on sample
population
 Simpler analysis  More complex analysis
 Rapid dissemination of  Slower dissemination of
results results
 Results not necessarily  Aims at generalizability
generalizable
 Triggers intervention  Looser link to intervention
Objectives of Surveillance

 Monitor Disease Trends

 Detect Increases in
Disease Incidence
 Trigger Investigation of
Etiology and Control of
Disease Transmission
Traditional disease notification
 Legal framework
 List of reportable (or notifiable) conditions
 Verification and analysis
 Investigation
 Public health intervention
 Dissemination of results
 Evaluation and updating
DISEASE SELECTION CRITERIA
 Incidence
 Morbidity
 Mortality / severity / lethality
 Communicability / potential for outbreaks
 Preventability
 Changing pattern in previous 5 years
 Socioeconomic burden
 Public health response necessary
 Public perception of risk
 International and other sector consideration
Rank (Priority for Canadian government, first 12 of 43)
1988 1998
1 Measles HIV
2 Tuberculosis AIDS
3 AIDS Laboratory confirmed influenza
4 Hepatitis B Tuberculosis
5 Pertussis Measles
6 Salmonellosis Rabies
7 Rubella Pertussis
8 H. influenzae Invasive meningococcal disease
invasive disease
9 Diphtheria Hepatitis C
10 Chickenpox Botulism
11 Meningococcal Poliomyelitis
infection
12 Gonococcal Creutzfeld-Jacob Disease
infection
Active Surveillance

 Reports are solicited from reporting

sources at established intervals
• Calling laboratories every Monday for
disease reports
 Limitations
• Resource intensive
• Difficult to maintain for extended
periods of time.
Passive Surveillance
 Sources send in reports of disease when they choose
 Current system for Communicable Disease Division
(CDD)
• PHIDDO: Electronic Disease Reporting & Electronic
Laboratory Reports
• Paper Morbidity and Laboratory Reports
 Limitations
• Completeness of reporting
Disease Reporting
VALIDITY OF REPORTS
(False positives)
 Surveillance definitions
 May be different from clinical definitions
 Laboratory confirmation
 The problem of nearly eliminated diseases
 Most positives are false positives
• Poor clinical diagnostic accuracy
• Importance of eliminating alternate Dx
 Only confirmed cases enter statistics
COMPLETENESS OF REPORTING
(False negatives)
 Varies by
 Type of reporting (active, passive)
 Source of reports
 Disease
 Need not be high, provided it is stable
 More important if intervention is possible
ROUTINE INVESTIGATION
OF REPORTED CASES
 MD, patient and/or relative are interviewed
 Not all cases can be investigated
 Intervention possible
 Transmissibility is high
 Case is unusual
 Outbreak is suspected
 ANALYSIS OF
SURVEILLANCE DATA

“Monitoring trends is the cornerstone

objective of most surveillance systems.”

Buehler, Modern Epidemiology (1998), p. 438

Standard outputs
 Periodic reports
 Mail and internet
 Monthly
 Commented
 Newsletter
 Special alerts
 fax and e-mail
 Annual report
ENHANCED SURVEILLANCE
 Priority problem identified
 Concept is elastic: traditional surveillance plus any
combination of
 Extra resources allocated
 Increased collaboration between government levels
 Standardized data collection
 Increased data quality control
 Access to better laboratory tests
 Increased analytic possibilities
 Other surveillance methods
 Greater potential to guide policy making?
SENTINEL SURVEILLANCE
 Does not seek completeness
 Uses purposely selected sources of information
 Prefers sources likely to observe earliest occurrence
of phenomenon under surveillance
 May be active or passive
 Relies heavily on real-time communication
 Positive findings often trigger other forms of
surveillance
CHOICE OF SENTINELS
 Physicians
 Pharmacies
 Laboratories
 Hospitals
 Public health Units, etc.
 Combination of sources
SUCCESS FACTORS (?)
 Link to professional organizations
 Keep it passive
 Provide feedback and other benefits
 Surveillance objectives must be
 Relevant
 Flexible
 Suggested by participants