13-09-2021

Field Epidemiology Training Program, Bangladesh (FETP,B)

Public Health Surveillance:

Objectives, Case Definition and Line Listing

Dr. Mallick Masum Billah

FETP,B

Suitability for Surveillance

What makes a health event

important?

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Important Health Events

 Affect many people

 Require large expenditures of resources
 Rare disease possible sentinel events
 Limited outbreak of severe disease
 Level of preventability

So how do we assess
these criteria in practice?

FETP,B

Measuring Health Events

 Frequency
– Case counts, incidence, prevalence, mortality

 Severity
– Case-fatality ratio, hospitalization rate, disability rate, years of
potential life lost, quality-adjusted life years

 Cost
– Direct and indirect costs

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Measuring Health Events

 Preventability
– Preventable fraction

 Communicability
– Secondary attack rate

 Public or Political Interest

 Health Disparities

FETP,B

A Surveillance System Is Designed With The Decisions

To Be Made In Mind

What decisions What data will be

will need needed for the
to be made? indicators?

All levels
participate

What information What indicators

will be needed? will be needed?

Elements of a surveillance system

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Steps in Planning a Surveillance System

 Establish objectives
 Develop case definitions

 Determine data source and type of system

 Develop data collection instrument

 Field-test methods

 Develop and test analytic approach

 Consider interpretation issues (e.g., thresholds)

 Develop dissemination mechanism

 Ensure use of analysis and interpretation

FETP,B

Steps in Planning a Surveillance System

 Establish objectives
 Develop case definitions

 Determine data source or data collection mechanism (type

of system)
 Develop data collection instrument

 Field-test methods

 Develop and test analytic approach

 Consider interpretation issues (e.g., thresholds)

 Develop dissemination mechanism

 Ensure use of analysis and interpretation

FETP,B

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Objectives of Surveillance

1. Establish baseline rate of disease

FETP,B

Steps in Planning a Surveillance System

 Establish objectives
 Develop case definitions
 Determine data source or data collection mechanism (type of
system)
 Develop data collection instrument
 Field-test methods
 Develop and test analytic approach
 Consider interpretation issues (e.g., thresholds)
 Develop dissemination mechanism
 Ensure use of analysis and interpretation

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Surveillance Case Definitions

In general, case definitions specify person,

place, time, and the level of certainty:
Level of Clinical Epidemiologic Laboratory
Certainty Symptoms Link Confirmation

Suspect  *
Probable  
Confirmed   
* Suspect cases may or may not have an epidemiologic link

FETP,B

Surveillance Case Definitions

 Case definitions evolve over time

 Development of an appropriate case definition depends
on the objectives of the surveillance system

 Capturing all cases must be balanced with the effort to

track down false positives

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Case Definition Tradeoffs

 Example – a highly “sensitive” case definition:

– Based on clinical symptoms
– Once cases captured, they are tracked and tested
– Captures most cases, but also captures lots of false-
positives

Would this case definition be good for a highly

endemic, food borne illness like Salmonella?

What about a rare vaccine-preventable disease like

measles?

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Step 4: Construct a Working Case Definition

 Simple,objective criteria
 Develop a case definition using:
– Symptoms or laboratory results
– Time frame
– Affected population (person)
– Location (place)
 Loose (sensitive) versus tight (specific) case
definition
 Categories of certainty, e.g., confirmed, probable,
possible

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Example: Case Definition for

Outbreak of Hepatitis A

 Clinical
– Confirmed case: Anti-HAV IgM +
– Probable case: Jaundice or elevated ALT
– Possible case: Any two of the following: Abdominal
pain, fever, nausea, anorexia, malaise
 Time – onset on or after April 1
 Place / Person – resident or visitor of
Dharamsala

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Validity / Accuracy

healthy ill

Test value

In an ideal test, the test values of healthy and ill subjects do not
overlap

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Validity / Accuracy

healthy
ill

Test value

In the real world, test values of healthy and ill subjects DO overlap

Problem with validity

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Validity / Accuracy

 Need threshold (cut-off) value to distinguish

“normal” from “abnormal” values
 Four possible combinations of disease and test
– True positive: ill with abnormal test
– True negative: healthy with normal (“negative”)
test
– False positive: healthy with abnormal test
– False negative: ill with normal test

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Validity / Accuracy

Threshold
healthy
ill
true
negative true
positive

false false
negative positive

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Sensitivity

 Sensitivity = among those with disease, probability of

a positive test
 Laboratory test: Proportion of persons with the
disease who have a positive lab test
 Surveillance system: Proportion of persons with the
disease who are detected by / reported to the
surveillance system
 Case definition: Proportion of persons with the
disease who meet the case definition

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Sensitivity

 Sensitivity = among those with disease, probability

of a positive test = 90%
 Laboratory test: 90% of persons with the disease
have a positive lab test
 Surveillance system: 90% of persons with the
disease are detected by / reported to the surveillance
system
 Case definition: 90% of persons with the disease
meet the case definition
 = 10% False negatives

FETP,B

Specificity

 Specificity = among those without disease,

probability of a negative test
= ability to correctly identify those who
do not have the disease
 Laboratory test: Proportion of persons without
disease who have a negative lab test
 Case definition: Proportion of persons without the
disease who are not included in the case definition

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Specificity

 Specificity = among those without disease,

probability of a negative test = 95%
 Laboratory test: 95% of persons without disease
have a negative lab test
 Case definition: 95% of persons without the
disease are not included in the case definition
 = 5% False positives

FETP,B

Sensitive vs. Specific Case Definition

of Gastroenteritis

 Sensitive case definition of gastroenteritis

– Nausea OR diarrhea

 Specific case definition of gastroenteritis

– Laboratory-confirmed Salmonella, Shigella, norovirus,
etc.

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Sensitive Case Definition

Most cases detected, but …

Many false positives

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Specific Case Definition

Few false positives

But missed cases

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Ebola Case Definition (Clinical)

 Proven — virus isolated or seen on EM, or IFA

> 1:64
 Probable — person living in area who died
with > 2 of headache, fever, abdominal pain,
nausea, vomiting, bleeding
 Possible — headache and/or fever > 24 hrs,
with contact with proven or probable case

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Step 5: Find Cases Systematically,

Develop Line List

 Conduct surveillance using case definition

– Active surveillance (e.g. review medical records)
– Try to identify all cases
 Collectdata on case-patients
 Create line listing

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Case Report Form

 Types of Variables:
–Identifying information
–Demographic information
–Clinical information
–Risk factor information
–Reporter information
–(Contact information,
sometimes)

FETP,B

What is a Line Listing?

 Linelisting = rectangular database similar to

spreadsheet
– Provides summary of key data about cases in an
outbreak
– Each row represents one case
– Each column represents one variable
 First column usually identifier — name,
initials, or ID number
– Can be paper or electronic
– Can be quickly reviewed and updated

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Which Variables to Include

Always include:
 Components of case definition
 Case name or identifying number
 Date of symptom onset (or specimen collection date)

Usually include:
 Age, gender
May include:
 Otherrelevant demographic variables (race,
occupation)
 Relevant risk factors

FETP,B

Thank You

FETP,B

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