Surveillance and Notification of

Communicable Diseases
 Objectives
By the end of the session the participants will be to:

• Define surveillance and purpose of surveillance.

• Describe the types of surveillance.
• Discuss the conceptual framework and components of a
surveillance system.
• Identify nurses role in surveillance
 Surveillance
• Surveillance is the ongoing, systematic collection, analysis,
and interpretation of outcome specific data for use in
planning, implementing and evaluating public health policies
and practices.

• "sur" means "from above"

and "veiller" means
"to watch”
 Key function of disease surveillance

– Early warning of the potential threat to

public health

– Monitoring (Disease specific or multi-

disease program)

– Providing information to plan public health

interventions

– Stimulating research
 Example of surveillance
• Early warning signs the CDC made the public for taking
prevention there is an outbreak of:

– SARS
– Bird flue (Avian Influenza)
– Potential threat from biological
or chemical agents
– Ebola
 Types of surveillance
Active:
• verify, investigate and validate the diseases in the
community and to detect more cases in the community
• more accurate, timely, short periods, more resource
intensive

Passive:
• doesn't verify and investigate: send the data without
verification.
• passive surveillance may give you the information you need
for future planning
 Types of surveillance
Sentinel Surveillance

• Encompasses a wide range of activities focused on

monitoring key health indicators in general or in
special populations.
• May be passive or active
• Key health events
• Clinics or other sites at which health events are
monitored
 Surveillance: General principle
Health Care System Public Health Authority

Reporting
Data Information

Analysis &
Evaluation Interpretation

Feedback

Action Decision

Surveillance (JPFCM, Jan. 2010) Ghaiath

13
 Elements of the surveillance System

All surveillance system involve six key elements

1. Detection and notification of a health event.

2. Investigation and confirmation (Epidemiological,
Clinical, Laboratory)
3. Collection of data
4. Analysis and interpretation of data
5. Feedback and dissemination of results
6. Response….A link to public health programs,
specifically actions for prevention and control.
Source: Adapted from
WHO 1999a
 Outbreak Detection and Response
Without Preparedness

First Late Delayed

Detection Response
Case

Opportunity
CASES for control

DA
Y
 Outbreak Detection and Response
With Preparedness and rapid response

Rapid
Early
Respons
Detection
e

Potential
First
Cases Prevented
Case
CASES

DA
Y
 Sources of data collection
• Mortality reports
• Morbidity reports
• Epidemic reports
• Reports of laboratory utilization (including laboratory test results)
• Reports of individual case investigations
• Reports of epidemic investigations
• Special surveys (e.g., hospital admissions, disease registers, and
• serologic surveys)
• Information on animal reservoirs and vectors
• Demographic data
• Environmental data
Flow of information data
 Vital Statistics Surveillance (VSS)
• Records of births and deaths: a basic but critical
cornerstone of public health surveillance
• Mortality data over past century show decrease in rate of
deaths due to infectious diseases; rate of death from non-
infectious causes remain steady
• Infant mortality rate (number of deaths among infants
per 1,000 live births) long used as indicator of overall
population health
• Birth data used to monitor incidence of preterm birth,
risk factor for variety of adverse health outcomes
 Vital Statistics
• In Pakistan vital statistics are available from National
institute of Population studies (NIPS) Islamabad, Pakistan.
www.nips.org.pk

• In Pakistan Demographic and Health survey is conducted

each year and published by NIPS.
 Disease Reporting/surveillance
• A structured approach to strengthen national communicable
disease surveillance systems could include:
– Assessment
– Prioritization
– SWOT Analysis of existing system
– Developing a strategic action plan
– Implementation
– Monitoring
– Evaluation
 Monitoring
• Monitoring in the context of surveillance and response
systems refers to the routine and continuous tracking of the
implementation of planned surveillance activities
(monitoring the implementation of the plan of action) and of
the overall performance of surveillance and response
systems.
Monitoring
 Evaluation
• Evaluation is the periodic assessment of the relevance,
effectiveness and impact of activities in the light of
the objectives of the surveillance and response
systems.
Evaluation
 Indicators
• Indicators are variables that can be measured repeatedly
(directly or indirectly) over time and provide measures of
change in a system.

• Indicators:
– provide useful information on the status of the system
and flag areas that need improvement
– usually expressed as simple counts, proportions, rates or
ratios
 Types of indicators
• Indicators can be classified in various ways. In the logical
framework approach (LFA), there are five types of indicators:

• Input
• Process
• Output
• Outcome
• Impact
 Indicators Types
• Input indicators are the resources needed to implement the
system

• Trained personnel, finance, standards and guidelines,

communication facilities, forms for surveillance, computers,
stockpiles for emergency response, and any other logistics as
deemed necessary.
 Types of Indicators
• Process indicators are used to monitor and track
implementation of the planned activities which are critical for
attaining the surveillance core functions

• such as training, supervision, development of guidelines and

tools, etc.
 Indicators Types
• Output indicators are measures of the immediate
results of the activities.
• Such as reports of surveillance data, feedback
• Outcome indicators are measures of the quality of
the surveillance system and the extent to which the
surveillance objectives are achieved.
• Such as use of surveillance data for policy and
program decisions, and appropriateness of outbreak
response.
 Indicators Types
• Impact indicators are measures of the extent to which the
overall objectives of the system are being achieved.
 Ways to improve Surveillance System

• Improve Awareness of Practitioners

• Simplify Reporting
• Frequent Feedback
• Widen the Net
• Active Surveillance
Filling the DEWS Form
 Filling the DEWS / Surveillance Form

• Compile the data from the Daily OPD Register by age and
sex for each Health event under surveillance
• Transfer the data on the Surveillance form
• Write the Morbidity (# of cases) and Mortality (# of
deaths) data clearly in the relevant section
• Write Zero if there is no case or death for a health event in
any age or sex group
• Submit the form to the relevant/focal authority (DHO/EDO
Health or Surveillance Coordinator) on daily basis
 General Information

Weekly Morbidity (disease) and Mortality (death)

Surveillance Reporting Form
Province: (Please send toDsiEcirtD:t O-H/WHO officSeubedvsiertrciyT/t Sehastliu: rday
before 12.00)
Town/Village/Camp: Population: Population <5yrs

Date: / / Epidemiological Week from Saturday: / /2009 to Friday / /2009

Supporting Agency/NGOs Health Facility Phone #

Name of contact Officer Phone #

 Events Under Surveillance
No of Consultations
Events Under Surveillance 0-<5yrs = >5 - < 15yrs 15-44yrs 45 + yrs
M F M F M F M F

01 Acute Diarrhoea
02 AWD/ Suspected Cholera
03 Bloody Diarrhoea
04 Acute Flaccid Paralysis (AFP)
05 Suspected Malaria
06 Acute Upper Respiratory Infection

07 Acute Lower Respiratory Infection

08 Suspected Measles
09 Suspected Meningitis
10 Acute Jaundice Syndrome
11 Neonatal Tetanus
12 Suspected Hemorrhagic Fever
13 Unexplained Fever >38.50 C
14 Scabies
15 Bronchial Asthma
16 Hypertension
17 Diabetes
18 Injuries

19 Severe Malnutrition
(wfh* < -3Z) Red Zone
Moderate Malnutrition
20
(wfh* -2 to -3Z) Orange zone
21 No. of Antenatal Consultations
22 No. of normal deliveries
23 ** No. of Pregnant women
referred
24 Others
25
26
27
Total Consultations
MORTALITY INFORMATION
Brief details of reported deaths
 Nurses role in surveillance

• Assessment of communicable disease risks to identify

major public health threats.
• Prioritization of public health threats to ensure that
surveillance is limited to the important public health
events.
• Assessment of systems to review strengths,
existing
weaknesses, and opportunities for strengthening
the systems.
• Development of a strategic plan of action based on the
findings of the assessment.

41
Health Indicators
 Crude death rate

• Crude Death Rate (CDR) = number of deaths during time period X

100,000 total population at mid-point of time period
• EXAMPLE:
• CDR for Peshawar 2012 = number of deaths in Peshawar in 2012_ X
100,000 total population Peshawar 2012
• Numerator = number of deaths in Peshawar in 2012 = 301
• Denominator = total population Peshawar 2012 = 30,726
• Constant = 100,000
• Time period = 2012
• CDR for Peshawar 2012 = 301 X 100,000 = 979.6/ 100,000 population
30,726
 Crude birth rate
• Crude Birth Rate (CBR) = number of live births during time period_ X
1,000 total population at mid-point of time period

• EXAMPLE:
• CBR for KPK 2012 = number of KPK live births in 2012 X 1,000
population of KPK in 2012

• Numerator = number of KPK live births in 2012 = 27,206

• Denominator = population of KPK in 2012= 1,819,046
• Constant = 1,000
• Time period = 2012

• CBR for KPK 2012 = 27,206 X 1,000 = 14.9/ 1,000

population
1,819,046
 Infant Mortality Rate
• Infant Mortality Rate (IMR) = number of infant deaths during time period X
1,000
number of live births during time period
• EXAMPLE:
• IMR for Peshawar 2001 = number infant deaths Peshawar 2012_ X 1,000
number of live births Peshawar 2012

• Numerator = number infant deaths Peshawar 2012= 50

• Denominator = number of live births Peshawar 2012 = 8,357
• Constant = 1,000
• Time period = 2012

• IMR for Peshawar 2012 = 50 X 1,000 = 5.9/ 1,000

live births 8,357
 Perinatal mortality Rate

• Perinatal mortality rate= number of perinatal deaths during time period x 1000
total number of births (still births + live births)

• Example:
• MMR in Peshawar = Number of perinatal death in Peshawar in X 1000
2012 Number of total births (still+live) in Peshawar

• Numerator = number perinatal death in Peshawar in 2012 = 10

• Denominator=number of total births (still+live) in Peshawar in 2012= 100,000
• Constant = 1000
• Time period= 2012

• PMR in Peshawar = 10 X1000 = 10 per 10,000 live birth.

100,000
 Neonatal Mortality Rate
• Neonatal Mortality Rate = number of deaths to children <28 days of age during time period X 1,000
number of live births during time period
• EXAMPLE:
• NMR in Peshawar = number deaths to age <28 days in Peshawar 2012 X 1,000
number live births in Peshawar 2012

• Numerator = number of deaths to age <28 days in Peshawar 2012= 41

• Denominator = number live births in Peshawar 2012= 8,357
• Constant = 1,000
• Time period= 2012

• Neonatal mortality rate for Peshawar 2012 = 41 X 1,000 = 4.9/ 1,000

live births
8,357
 Maternal Mortality Rate
Maternal Mortality Rate= number of maternal death X
10,000
• Example: number of live births
• MMR in Peshawar= Number of maternal death in Peshawar X 10,000
Number of total live births in Peshawar

• Numerator = number of maternal death in Peshawar= 10

• Denominator=number of live birth= 100,000
• Constant = 10,000

• MMR in Peshawar= 10 X10,000 = 1 per 10,000 live

birth.
100,000
 Incidence Rate
• Incidence Rate = number of new cases of a disease during time period X constant
population at risk during time period
• EXAMPLE:
• Diabetes Incidence = number of new cases of Diabetes in Peshawar in 2012 X
1,000 (population of Peshawar 2012-number already diagnosed with diabetes before
2012)

• Numerator = number of new cases of Diabetes in Peshawar in 2012= 20

• Denominator=(population of Peshawar 2012 - number with diabetes
already)=(30,726-367)=30,359
• Constant = 1,000
• Time period = 2012

• Incidence Rate of diabetes in Peshawar 2012 = 20 X 1,000 = 0.65/

1,000 population 30,359
 Prevalence Rate
• Prevalence Rate = _number of existing cases of a disease during time period_ X 100
total population during time period
• (Note: Prevalence is often expressed as a percentage)

• EXAMPLE:
• Diabetes Prevalence Rate = _number of diabetics in Peshawar 2013_ X 100
Peshawar 2013 total population of Peshawar 2013

• Numerator = number of diabetics in Peshawar 2013= 387

• Denominator = total population of Peshawar 2013= 30,726
• Constant = 100
• Time period= 2001

• Diabetes prevalence Rate Peshawar 2013 = 387 X 100= 1.3%

30,726
 General Fertility Rate
• Fertility Rate = number of live births during time period X 1,000
total population of females age 15-44 at mid-point of time period
• EXAMPLE:
• Fertility Rate for Peshawar 2013 = number of live births in Peshawar in 2012 X
1,000
population of Peshawar females 15-44 in 2012

• Numerator = number of live births in Peshawar in 2012 = 169

• Denominator = population of Peshawar 15-44 in 2012= 3,105
• Constant = 1,000
• Time period = 2012

• Fertility Rate for Peshawar 2012 = 169 X 1,000 = 54.4 /1,000 females ages 15-44
3,105
 The dependency ratio can be expressed
as:
• children (0-14) and elderly (65 and over)x 100
those of working age
 e.g. UK 1971 (figures in millions):
• 13 387 + 7307 x100 = 65.45
31616

So for every 100 people of working age there

were 65.45 people dependent upon them
 Sex ratio
• Sex ratio is the ratio of males to females in a
population.
The Sex-Ratio (SR) is defined as the number
of males/number of females:
SR = m/f.
The numerator of the Sex-Ratio (males) is not part
of the denominator (females),
thus the SR is not a proportion, which would be
Pmales = m/(m+f).
 References
• Baig M, Shaikh B. Disease Surveillance System: A Mandatory Conduit for
Effective Control of Infectious Diseases in Pakistan. Asia-Pacific Journal of
Public Health. 2012;24(4):586-594.