PRINCIPLES OF DISEASE MANGEMENT

AND CONTROL II
DISEASE SURVEILLANCE
LESSON OBJECTIVES
By the end of the lesson, student should be able to:
 explain the term disease surveillance
 state the objectives of surveillance
 explain the types of surveillance
explain surveillance functions (core and support
functions) explain the term IDSR
Community based surveillance
 Introduction

During the 1970s and 1980s, the national and global

focus of the Expanded Programme on Immunization
was primarily;
 on reaching the Universal Childhood Immunization
goal of 80% coverage by 1990.
In the 1990s, national program managers and
donors started to look more closely at the effect of
immunization services on the incidence of disease,
and disease surveillance became a more prominent
activity.
 Surveillance

Surveillance is a keeping watch over a person, group, etc.

 or continuous observation of a place, person, group, or
ongoing activity in order to gather information, or
attentive observation, as to oversee and direct someone
or something.
 Surveillance is the ongoing systematic collection,
analysis, and interpretation of health data.
It includes the timely dissemination of the resulting
information to those who need them for action.
Surveillance is also essential for planning,
implementation, and evaluation of public health practice.
 Cont’n

According the Centers for Disease Control and

Prevention (CDC), epidemiological surveillance:
 is “the ongoing systematic collection, analysis, and
interpretation of health data essential :
to the planning, implementation, and evaluation of
public health practice, closely integrated with the
timely dissemination of these data to those who need
to know.”
Surveillance in general means to watch over carefully
or to observe any event. For general example use of
CCTV is also a kind of surveillance.
 Surveillance in public health is the continuous:

watching of the incidence and distribution;

 of health-related events through systematic
collection, analysis and interpretation;
 of data needed for the planning, implementation,
and evaluation of public health practice.
It can be carried out to monitor changes in disease
frequency or to monitor changes in the levels of risk
factors.
Surveillance is systematic and ongoing process
 Basic Principles of Surveillance

 There are 3 basic principles of surveillance:

 Systematic collection of data
 Consolidation and analysis collected data
Dissemination of information by means of narrative
epidemiological reports.
 Systems of Surveillance

Notifiable disease - reporting surveillance:- by

legislation, health care providers must report
specified infectious diseases by any means possible
 Laboratory – based surveillance:- have been used to
detect outbreaks, characterizing causative agents;
providing basis for analyzing national trends.
 Hospital – based surveillance:- logical source for
data on illness problems
 Population – based surveillance:- collects and
analyzes medical information on all persons in a well
– defined population.
 Systems of Surveillance cont.

Surveillance is an essential part of disease control.

There are a number of ways of undertaking
surveillance for communicable disease control;
 the most important being a routine system of
reporting cases within the health system.
The routine information systems used for disease
surveillance in Ghana includes:
 Hospital records Routine periodic returns e.g.
monthly reports Vital records / statistics Notifiable
disease reporting CD forms
 Events that may require surveillance

Epidemic prone disease e.g.

 yellow fever, cholera,
 CSM
 Nutritional status and malnutrition
Animal reservoirs and vectors of communicable
disease
 Environmental pollution e.g. water
Demographic events e.g. birth, deaths, etc.
Characteristics of Ideal Surveillance:
An ideal surveillance should be:
Simple
Timely
Representative
Flexible
Sensitive
Strong predictive value
Acceptable to the public health care providers
Cost-effective
 The systematic collection of all relevant data

Examples of sources of epidemiological data in the

surveillance of disease include the following;
 Registration of deaths
 Notification of disease and reporting of epidemics
 Laboratory investigations
 Data from routine screening e.g. blood donors
 Investigation of individual cases and epidemics
 Epidemiological surveys
 Data from clinics, health centers, hospitals and other service
institutions
 Distribution of the animal reservoir and the vector
 Production, distribution and care of vaccines, sera and drugs
 Demographic and environmental data
 Sources of Surveillance Data continuation
•
Non medical statistics, e.g. consumption of specific foods
Morbidity and mortality reports
 Special reports of field investigations of epidemics and
individual cases
 Isolation and identification of infectious agents by
laboratories
Vaccine utilization uptake and side effects
 Information regarding immunity levels in segments of the
population
Other relevant epidemiological data
Sentinel sites
 Basic ingredient for surveillance

A good network of motivated people

 Clear case definition and reporting mechanism
Efficient communication system
 Basic but sound epidemiology
 Laboratory support
Good feed back and rapid response
 Sources of Surveillance Data cont.

NOTE: A report summarizing these data should be

prepared and disseminated to all co-operating
parties and others with a need to know the results of
the surveillance activities.
 For rapid assessment of incidence, more and more
countries are also introducing sentinel system
(sentinel meaning ‘guard’ or ‘watchman’)
in which a sample of all general practitioners in the
country are asked to report clinical diagnosis of
certain diseases at a regional or national level on a
weekly basis.
 Disease surveillance
Disease surveillance is the ongoing collection,
analysis, and interpretation of data to determine
disease trends and patterns.
 Disease surveillance is an epidemiological practice
by which the spread of disease is monitored in order
to establish patterns of progression.
 The main role of disease surveillance is to;
 predict, observe, and minimize the harm caused by
outbreak, epidemic, and pandemic situations;
as well as increase knowledge about which factors
contribute to such circumstances.
 Disease surveillance

Disease surveillance provides information such as:

Disease incidence, morbidity, and mortality, and progress in
achieving disease control goals.
 Changes in patterns of morbidity and mortality among
different age groups in different geographical areas and
among different economic, social, or cultural groups
Impact of immunization strategies on disease incidence
 Disease trends
The overriding value of disease surveillance, however;
 is its use as a tool to identify the presence of infectious
diseases and guide actions to prevent them from becoming
threats to public health.
 Objectives / Importance of Disease Surveillance

Early detection of disease outbreaks leading to rapid investigation and control

1.

(The recognition of acute problems that demand immediate action e.g.

 the recognition of an outbreak of a major epidemic infection such as cholera;
 or the fresh introduction of it into a previously uninfected area must be;
 recognized promptly so that infection may be confined to the smallest
possible time}
2. Monitoring of long-term trends in disease occurrence to enable early
investigation and application of appropriate intervention
3. Evaluation of disease control measures
4. Provision of information for health service planning and resource allocation
5. Collection of data on rare and newly recognized diseases for research purposes
6. To identify population groups at risk of diseases
2. Surveillance is used to provide a broad

assessment of specific problems in order to discern

long-term trends and
 epidemiological patterns to guide and monitor
interventions, and finally to assess their impact.
Thus surveillance provides the scientific basis for
ascertaining the major public health problems in an
area,
 thereby serving as a guide for planning,
implementation and assessment of programmes for
the control of communicable disease.
Steps in surveillance system
 Steps for disease surveillance

Detect cases
Collect any needed information to be sure
Record and report to the appropriate health
personnel
Analyze and interpret the data
Investigate rumors/suspects
Take appropriate actions
Supervise and provide feedback
Follow up cases
Monitor and evaluate
 Importance of surveillance:
To assess the health status
 All the data collected are the reflection of health of people
 Keeps the record of existing health problems
 Helps in the interpretation of mortality and morbidity status
To detect the change in the disease trend and health
practices
 Continue recording of data notifies about the disease trend
 Keeps the track of disease
Surveillance is also helpful for finding the natural
history of disease
 • Collection of data for Planning, Monitoring and
Evaluation

 The data required for PME is provided by surveillance

 It is the base for evidence-based policy formation
 Helps the program developer in priority setting
 Also helps in assessing the effectiveness of the interventions
• Early warning and detection of outbreaks

 Surveillance notifies about the disease

 All the data too helps in detecting the outbreaks
 Hence helps in preparedness
To estimate the size of a health problem
To detect epidemics or define a problem
To facilitate emergency planning
 Types of disease surveillance

 Several types of surveillance are used in national programs. The

choice of method depends on the purpose of the surveillance action.
 In general, types of surveillance methods describe:
 a focused location for surveillance (such as health facility-based
surveillance or community-based surveillance).
 a designated or representative health facility or reporting site for
early warning of epidemic or pandemic events (sentinel
surveillance).
 surveillance conducted at laboratories for detecting events or trends
not necessarily evident at other sites.
 disease-specific surveillance involving activities aimed at targeted
health data for a specific disease.
 Regardless of the type of surveillance, the important issue is of that
the health data is used for public health action.
 Types of disease surveillance

 1. Facility-Based Routine Surveillance

 In many countries, health workers are required to report on the
number of individuals that come to their facility and are diagnosed
with reportable diseases.
 These reportable diseases are usually diseases that have outbreak
potential, such as cholera, polio, and measles, or diseases that are
targets of national control programs, such as malaria and tetanus.
 Data on individual patients, which are recorded in patient registers,
are used to calculate the number of cases of reportable diseases
diagnosed by health facility staff over a certain period of time.
 These data are periodically reported to district authorities who
compile and send them to higher administrative levels.
 This process of detecting and reporting information on diseases that
bring patients to the health facility is known as passive surveillance.
 2. Active Surveillance
One way to overcome the limitations of passive
surveillance and get a better picture of disease
burden in the community;
 is for health workers to visit health facilities and
communities to seek out cases.
This is known as active surveillance.
Active surveillance involves the vigorous search for
data by survey or case search or based on special
surveys set up with the specific objective of obtaining
data for surveillance.
 Types of disease surveillance cont.

In active surveillance, participants in the surveillance system

seek reports based on regular basis rather than waiting for
the reports.
Since passive surveillance has limitations due to its lack of
access to some groups within the population, active
surveillance is often used to enhance the completeness of a
passive surveillance system.
Active surveillance is also more expensive than a passive
system and requires considerable additional effort to
organize.
 This means that active surveillance is usually conducted on a
limited segment of the population and for only a brief period.
 Types of disease surveillance cont.

Active surveillance is, therefore, used to gain targeted

insight into a situation and not collect routine data
over a long period of time.
 Routine surveillance by health facilities, whether
passive or active, is often hampered by the difficulty
of making accurate diagnoses.
 Health workers may lack the proper equipment or
training for diagnosis in the health facility, and
laboratory services are often not available to confirm
clinical diagnoses.
 •
Cont'n

In certain instances, health workers conduct case

based investigations to learn more about a specific
illness pattern,
 for example, when there is a suspected case of a
disease as polio, or during suspected outbreaks of
epidemic- prone diseases such as yellow fever.
 In case-based investigations, health workers record
information such as the patient’s name, age,
vaccination status, location, date of disease onset,
suspected diagnosis, and laboratory results (when
available).
 3. Passive Surveillance

 Surveillance in which the available data on diseases or conditions are

used
 It refers to regular monitoring or reporting of the cases without active
involvement in identification/reporting by the health personnel
 Simple and very easy to carry out
 All institutions that provide health services to general people are the
part of this surveillance.
 They forward their records to the designated departments where all
the reports are compiled
 Uniform format of reporting is followed
 Health management information system of government is an
example of passive surveillance
 Inconsistency of recording can cause problem as things may not be
taken seriously all the time
 Passive Surveillance Cont'n

In passive surveillance, data collection is based on the patients

/ clients who report to the health facility.
 Or based on the central collection of data generated locally as
part of routine health service functions.
Passive surveillance involves the collection of data as part of
routine provision of health care services.
Passive surveillance yields only limited data because many sick
people do not visit a health facility and because those cases
that do show up may not be correctly classified, recorded, or
reported.
 If managers fail to fully understand and account for these
limitations, they may incorrectly interpret trends and patterns
of infectious diseases.
 4. Sentinel Surveillance

 It is a surveillance system which is used when the need of

high quality data cannot be met through passive surveillance
 It is a system where specific catchment area is selected for
surveillance.
 Selection of sentinel surveillance site depends on possibility
of high probability of cases/disease
 It deliberately involves limited network of carefully selected
reporting sites.
 Example: a network of large hospitals might be used to
collect high-quality data on various diseases
 Sites are selected on the basis of population flow, previous
outbreak of disease, high presence of risk group, etc.
 Sentinel Surveillance is not suitable for detecting rare disease
 5.Community-Based Surveillance
 Epidemics are a constant threat to the well-being of communities
everywhere, and more especially so in societies where resources
are scarce.
 Managing epidemics, or preferably preventing them, is a priority
for the International Red Cross and Red Crescent Movement
worldwide.
 The role of communities in preventing, detecting and responding
to local health threats is critical in improving the lives of millions
across the world.
 One of the principal advantages of community based surveillance
(CBS) is that it ensures effective communication of unusual events;
 or changes in the health status of residents in a community to
authorities and, importantly, gives a voice to communities.
 This channel of communication enables an early detection
and response to potential epidemics;

making it possible to stop them before they start .

There is a need then to strengthen disease surveillance at
all levels and especially at the community level.
Taking into account the experience and lessons from the
Ebola virus disease outbreak in West Africa:
 and the health challenges associated with the
displacement of people by internal conflicts;
 the World Health Organization (WHO) Regional Office
for Africa developed a guide for establishing community-
based surveillance (CBS);
 for preparedness and response efforts for disease
outbreaks in the countries.
 Community-Based Surveillance Cont'n
 With training, members of the community can expand facility-based
surveillance by detecting and reporting cases that may go undetected by the
health facility.
 In community – based surveillance,
 the first point of data collection is at the community level, usually by
community members who report to health workers for subsequent follow –
up and action.
 A good example of this is the use of community members to detect cases of
guinea worm (dracunculiasis).
 In villages where the disease is endemic,
 volunteers are trained to detect and report cases using a standard diagnostic
criterion, e.g.,
 painful legs that have skin ulcers with worms protruding.
 They then may undertake treatment, referral, and containment measures
such as bandaging the ulcer, instructing infected persons not to bathe in
water from ponds and streams, and promoting the use of filtered drinking
water.
 Types of disease surveillance cont.

 Community-based surveillance needs the support of trained health care

workers who in turn provide training to the community on how to recognize the
disease and how to respond when people are ill.

 While the focus of community surveillance may be on a specific disease,

community members may also be trained to detect an array of health problems.

 Community members and health workers can work together to organize

transport, childcare, and other assistance and, sometimes, provide medical
supplies, treatment, and vaccinations.

 Reports by community members should be incorporated into the overall

surveillance data managed by health personnel.

 Health systems should also provide feedback to the community about disease
patterns in their own and surrounding areas.
 Types of disease surveillance cont.

 Community-based surveillance can be very useful in detecting and

treating some illnesses.
 However, it generally has a high error rate and should be used carefully.
 Case definitions need to be very simple and specific for community
identification and this means that diagnoses need to be confirmed by
someone with more advanced training.
 While it is always wise to involve the community as much as possible in
health initiatives, community-based surveillance is not appropriate for
all conditions and situations.
 Health workers should carefully test the community-based approach
before initiating it and should be prepared to regularly monitor
activities ;
 to ensure that definitions are being applied correctly and that the health
of the community members is being served well by this approach to
surveillance.
Community-based surveillance is one component of the
integrated disease surveillance and response system.
As the name implies, its overarching objective is to
establish a sustainable, community-level surveillance
system in which persons resident in the community keep
watch to detect occurrences of infectious diseases as well
as unusual health events that might indicate the presence
of disease, and take timely and appropriate action
including reporting the disease cases and health events to
health authorities for investigation and further action.
 Specific objectives :
 To establish a surveillance system that originates from the
community and empowers community members to take action
in the event of a disease outbreak or other adverse health event
 To demonstrate that the surveillance system will promptly
identify and report the information, indicators and parameters
selected for surveillance
 To present the data collected graphically in a manner that will
facilitate easy interpretation and quicker response
 To strengthen the organizational capacity of the community and
the health institutions to respond with action to the information
from the surveillance
 To establish a reliable information transmission system between
the village, sub-district, district, regional and national levels
 Rationale for a CBS system

 Only a small proportion of the rural population in Ghana is within easy

reach of a health facility with trained personnel.
 In addition, illiteracy and ignorance of the causes of disease and the
availability of services to prevent and treat disease preclude the people’s
use of the health facilities that do exist.
 As a result, very little is known about the health status and needs of these
populations because such information is based on the data gathered at
health facilities.
 In an effort to extend health coverage to these remote groups, outreach
services were introduced to cover all the villages within the catchment area
of each health facility.
 However, taking as an example areas such as the Northern Region, where
facilities are few and settlements are kilometers apart,
 the outreach system increased coverage by only a small proportion, to less
than 40% of the population.
The CBS system, modelled on the use of Northern
Region community volunteers to detect and report
cases of guinea worm disease, attempts to remedy
this situation.
Communities play an important role in the
detection, notification and reporting of a single case
or a broader outbreak of a communicable disease.
 •
Community members can be mobilized to recognize and to report adverse events to the
nearest health authorities especially if they are trained

 to be aware of the signs and symptoms of designated priority diseases and of the risk of epidemic
posed by the diseases.
 Outbreak of diseases such as meningitis and cholera that may currently rage for some time before
health authorities learn of them are instead observed by the CBS worker because ;
he – or she – knows virtually everybody in the community, then reported and recorded.
 Community-based surveillance can also be used to overcome cultural barriers to the reporting of
disease.
 For example, due to cultural beliefs in many parts of Ghana, neonatal death is not considered to be
death, so it is not reported or registered in mortality data.

 A mother dying during labour is considered a bad death; it is best not to discuss it and, as a result,
it too is seldom recorded.
 Like health facilities, authorities that register and issue births, deaths and burial certificates are
stationed in only a few towns.
 Because they are not available in many small communities, they record only a small proportion of
these events.
 While a CBS system is not meant to replace the facility-based surveillance system but rather to
complement it, the range of parameters that CBS can measure is very wide and useful.
 Cont’n on steps
Data Analysis
All the collected are then analyzed
The data are converted in terms of rates, ratios,
proportion, figures etc.
Interpretation and action
Surveillance doesn’t stops in data collection
Wise judgement needs to be made
The information needs to be disseminated so that
the further action are taken
 Other uses of techniques of surveillance

• The techniques of surveillance are now being

applied to the control of non infectious disease
such as;
• Environmental hazards associated with atmospheric
pollution, ionizing radiation and road traffic
accidents
Diseases such as cancer, atheroma and other
degenerative diseases
Social problems such as drug addiction, juvenile
delinquency and commercial sex work
 Limitations of Surveillance:

Surveillance depends upon the reporting so

underreporting could be a problem.
Inconsistency in reporting
Reporting may not be representative
Takes time for data collection, analysis and
interpretation
Surveillance is on the tool of epidemiology it is not
the solution to health problem.
Cont'n
 The guide has two main objectives:

(a) To help countries build and strengthen the

capacity of communities to conduct effective
surveillance and response activities in line with
Integrated Disease Surveillance and Response
(IDSR) (2010) strategy;
 (b) To improve the flow of surveillance information
between the community and the local health
facilities.
 Information you need to know before
community surveillance
Map the community properly.
You should know where people live and work.
Scan the whole community by making house-to-house visits.
 If the community is large, divide the work up into smaller
sections or areas.
 Establish who is vulnerable in the community.
 Doing this will help you to identify people who are more
likely to fall sick.
 Start surveillance.
This will help you to communicate specific health messages
and information, and to refer sick people promptly to health
facilities.
 Cont’n of information
Remember that, through your surveillance and your presence in
the community;
 you are able to obtain information that could be helpful to
others who are tackling the epidemic.
 Communicate such information to your local branch, other
volunteer teams and health authorities.
This is called “reporting”.
Remember that reporting must be systematic. (well organized
or methodical)
To avoid confusion, everyone who reports should follow the
same methods.
 Talk to your local branch and the health authorities to find out
what reporting system will work best for your work and your
situation.
 • What you can do

 Map the community

 Identify who in the community may be vulnerable to the disease.
 Familiarize yourself with the disease that may be present in your
community, including its signs and symptoms.
 Establish surveillance teams to actively look for sick people.
 Allocate different areas of the community to each team.
 When you detect people who are sick with the disease, assess how severely
ill they are;
 and whether they need to be referred to a health facility.
 If sick people can be cared for at home, show their families what to do and;
 provide them with information and supplies, where possible.
 Record the cases you find and pool your records with those of other teams;
to build a clear picture of how the disease is spreading in the community.