Surveillance is

Information for Action

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
 Types of Surveillance
1. Passive (Routine reporting system)

Hospitals, health centers, health facilities.

Reporting is governed by existing local rules.
Advantages:
• Inexpensive.
• Standardized.
• Good for monitoring large numbers of typical health events
Disadvantages:
• Under-reporting is a problem
• Incomplete data
• Busy doctors & nurses

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 Types of Surveillance
2-Active (Sentinel reporting system):
Collection of data on a specific disease for a relatively limited period
of time.
By selected health units, certain physicians,…
Advantages:
• More consistent pictures.
• Motivated.
Disadvantages:
• Not representative
• Active surveillance is relatively expensive practice.
• It is usually limited to disease elimination programs and to short-
term intensive investigation and control activities, or to seasonal
problems, (e.g. Influenza, arboviruses).

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8/4/1428 Dr. Salwa Tayel 5
 Uses of Public Health Surveillance
• Estimate magnitude of the problem
• Portray the natural history of a disease
• Determine distribution and spread of illness
• Detect outbreaks
• Generate hypotheses, stimulate research
• Evaluate control and prevention measures
• Monitor changes in infectious agents
• Detect changes in health practices
• Facilitate planning
COMMUNICABLE DISEASE
SURVEILLANCE or RESEARCH?
• Ongoing
• Generates hypotheses
• Incomplete data on
population
• Simpler analysis
• Rapid dissemination of results
• Results not necessarily
generalizable
• Triggers intervention
• Time-limited
• Tests hypotheses
• Complete data on sample
• More complex analysis
• Slower dissemination of
results
• Aims at generalizability
• Looser link to intervention
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
Purposes of Public Health Surveillance

• Public health surveillance provides and

interprets data to facilitate the prevention
and control of disease.
 Evaluate control measures of MEASLES
United States, 1963-1998
Reported Cases (Thousands)
Vaccine MEASLES
MEASLES — — by
by year,
year, United
United
500
500 licensed States,
States, 1983–1998
1983–1998
450
450

400
30
400

Reported Cases
25
25
350
350

(Thousands)
20
20 20
300
300
15
15
250
250 10
10 10
200
200 55

00
150
150
1983
1983 1988
1988 1993
1993 1998
1998
100
100 Year
50
50

00
1963
1963 1968
1968 1973
1973 1978
1978 1983
1983 1988
1988 1993
1993 1998
1998
Year
Sources and Methods for Gathering
Data
Three main sources:
• Individual Persons
• Health-care providers, facilities, and records
— Physician offices
— Hospitals
— Outpatient departments
— Emergency departments
— Inpatient settings
— Laboratories
3. Environmental conditions
— Air
— Water
— Animal vectors

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Methods used to collect the health-
related data
1. Environmental monitoring
2. Surveys
3. Notifications
4. Registries.

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 Surveys
• Surveys, uses a “structured and systematic gathering of
information” from a sample of “a population of interest to
describe the population in quantitative terms.”

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Notification
• A notification is the reporting of certain diseases or
other health-related conditions by a specific group,
as specified by law, regulation, or agreement.
• Notifications are typically made to the state or local
health agency.

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 Registries
• Reregistery is a method for documenting or tracking
events or persons over time.
Examples:
• Registries of vital events (birth and death certificates) are
required by law and contain important health-related
information.
• A disease registry (e.g., a cancer registry) tracks a person
with disease over time and usually includes diagnostic,
treatment, and outcome information.

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Analyzing and Interpreting Data
• Analyzing by time
• Analyzing by place
• Analyzing by person
 Interpreting results of analyses

• Observed increases or decreases in disease incidence or

prevalence might be an artifact.
• Common causes of artifactual (not true) change in
disease occurrence are:
• Changes in local reporting procedures or policies (e.g., a
change from passive to active surveillance).
• Changes in case definition (e.g., AIDS in 1993).
• Increased health-seeking behavior (e.g., media publicity
prompts persons with symptoms to seek medical care).
• Increase in diagnosis.
• New laboratory test or diagnostic procedure.
• Increased physician awareness of the condition, or a new
physician is in town.
• Increase in reporting (i.e., improved awareness of
reporting).
• Outbreak of similar disease, misdiagnosed as disease of
interest.
• Laboratory error.
Disseminating Data and Interpretations

Data and interpretations should be sent to:

• those who provided reports or other data (e.g., health-care
providers and laboratory directors).
They should also be sent to those who use them for
• planning or
• managing control programs,
• Administrative purposes,
• or other health-related decision-making.
Aims of surveillance (1)
Actions: examples
 Manage contacts of a case
 Detect outbreaks
 Early warning
 design/change vaccination policy
 Design policy re antimicrobial resistance
 Evaluate interventions to improve them
 Certify elimination/eradication
 Aims of surveillance (2)
Public Health Aims
 Assess public health status (monitor trends, detect
outbreaks)
• Prevent and control disease
 Define public health priorities
• plan considering impact of hazard, exposure, disease
 Evaluate public health programmes
• make decisions regarding interventions
 Stimulate or inform research
• generate hypothesis, inform methodologie
Step in setting up surveillance (1)
1. Understand the problem
2. Identify opportunities for prevention & control
• interventions
• target audience
3. Set objectives
4. Specify requirements to meet objectives
5. Design
• Case definitions & indicators
• Data needed
• Data sources
• Data transfer
Step in setting up surveillance (2)
6. Translate information into action
• Analyze
• Interpret
• Disseminate
7. Evaluate surveillance system
 1. Identify opportunities for prevention & control

Transmission Environment
Exposure
vector
6. Prevent transmission Direct
1. vaccination
e.g. universal precaution
Source
infection
infection 4. isolation/treatment

5. Ecological management
2. Prophylaxis
Disease
3. treatment
Reservoir
Death Recovery
Disability
2. Identify opportunities for prevention & control
Target audiences

 Public Health professionals

 Government / politicians
 Clinicians / Microbiologists / Control of Infection
staff
 Environmental Health professionals
 Health service managers
 Health educators/ teachers
 Public
3. Set objectives
SMART
 Specific
 Measurable
 Acceptable and action oriented
 Realistic
 Time related
3. Set objectives - examples

Vague..
 to estimate the prevalence of hepatitis C
 To detect outbreaks of measles
Specific, measurable, action-oriented & timed
 To assess the prevalence of hepatitis C in Pakistan in
order to allowing planning of specific Health care
needs for the coming 20 years.
 To detect early time and place clustering of measles
cases in order to ensure timely control of outbreaks.
4. Requirements of the system
Keep it as simple as possible!!
 Timeliness
 Sensitivity
 Specificity
 Completeness of information
 Representativeness
 acceptability
5. Design - case definitions

Report

Lab confirmed

Clinical specimen

Seek medical attention

Symptoms
Infected
Exposed
5. Design – examples of data
needed
 Numerators
• number of cases
• number of resistant strains
 Denominators
• Population under surveillance
• Life births (CRS)
• Bacterial isolates (AMR)
5. Design - data sources (1)
 Health service
• Notifications
• Laboratories
• Disease registries
• Community services
• Emergency services
• Screening programmes (antenatal, blood
donors)
• Pharmacy / over the counter drugs
• Vaccination programmes
5. Design – data sources (2)
 Veterinary
• Animals (domestic, wild)
• Food
 Environment
• Food
• Water
• Air
 Population statistics
• Deaths
• denominators
5. Design – data sources (3)
Issues
 Cost
 Representativeness
 Comparability
 Confidentiality
 Acceptability
 Data quality
 Timeliness
 Commercial sensitivity
5. Design – data transfer
 Existing infrastructure
 Methods
• Web-based
• Telephone
 Frequency
 Zero reporting
5. Design- addition design issues

• Sampling vs Comprehensive
• Aggregated vs Individual data
• Active vs passive
• Statutory vs voluntary
• Confidential vs Anonymous
• Security
6. Information into action (1)
 Analysis
• Descriptive (time, place, person)
• Time series
• Outbreak detection
• Molecular epidemiology
• Geographical information
systems (GIS)
 Interpretation
• System and data characteristics and changes
• Chance, bias, truth
6. Information into action (2)
 Dissemination of information
• Develop outputs in consultation with users
• Appropriate level of detail for action
• Regular review of usefulness
• Avoid information overload
7. Evaluation of surveillance
system

Did the system do what it set out to do?

Surveillance - the challenges
 Surveillance or research needed?
 Reliability
• Crude and inaccurate
• Incomplete
• Accurate denominators
 Sustainability
• Victim of success of control
 New threats
• Emerging infections
• Bioterrorism
 Timeliness
 Human Rights
• Data protection
Surveillance – the opportunities
 Near patient testing
 Less invasive diagnostics (oral fluid)
 New molecular typing method
 Electronic patient records
 ‘New’ data sources
 Behavioral surveillance
 Syndromic surveillance
 On-line, web-based system
• Data entry
• Dissemination of information
 New analysis method
• GIS
• Bio-informatics
• modelling
 Surveillance is a cyclical process
Health care system Public health authority
Reporting
Event Data
capture

Real World!... Analysis &

Expected Interpretation
changes

Dissemination
intervention information