Surveillance

Leonardo DG. Macam Jr., RMT MPH

Lecture Objectives
 To define surveillance
 To explain uses of surveillance
 To describe criteria for selecting health
events for surveillance
 To give examples of various surveillance
systems in the Philippines
Surveillance
 Surveillance is being there, watchful
waiting
 Anticipating
Surveillance
 The ‘eyes and ears’ of public health
 Provides information through which
public health program can act
effectively or efficiently
Surveillance
Public Health Surveillance:
 The close monitoring of the occurrence selected
health conditions in a population
 Originally for basic control of infectious diseases
 Expanded to:
 Information on diseases
 Injuries
 Information on risk factors (personal and environmental)
What Is Surveillance?
 Centers for Disease Control and
Prevention (CDC): epidemiologic
surveillance is “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.”
Why Is Surveillance
Important?
 Collecting data is merely one step
 Critical goal is to control and/or prevent
diseases
 Any data collected must be organized and
carefully examined
 Any results need to be communicated to
public health and medical communities
Objectives of Surveillance
 Epidemic (outbreak) detection
 Monitoring trends in endemic disease
 Evaluation of an intervention
 Monitoring progress towards a control
objective
 Monitoring program performance
 Estimate future disease impact
Why Is Surveillance
Important?
 Vital to communicate results
 During potential outbreak so public health
and medical communities can help with
disease prevention and control efforts
 During non-outbreak times to provide
information about baseline levels of
disease
 Baseline provides information to public health
officials monitoring health at community level,
serves as reference in future outbreaks
Surveillance: General Principle
Healthcare System Public Health Authrority

Reporting
Event Data

Analysis & Interpretation

Real world…
expected
changes
Decision

Intervention Information
(Feedback)
Principles of Surveillance
 Surveillance is not just information process but
management structure as well
 Surveillance provides the information base for
public health decision making
 Surveillance must continually respond to the
need for new information about health-related
states or events
 Surveillance must accommodate changing
priorities and needs of stakeholders
Surveillance: Basic Ingredients
 A good network of motivated people
 Clear case definition and reporting mechanism
 Efficient communication system
 Basic but sound epidemiology
 Laboratory support
 Good feedback and rapid response
 Surveillance: Data flow
Peripheral level Clinical (suspected)

Intermediate Level Supportive

laboratory data
+
epidemiological
link (probable)

Central Level Ministry of Health (DOH) Diagnostic

Laboratory
(Confirmed)

Regional/International Level WHO Regional Reference Laboratory

WHO
Major Surveillance methods
 Mandatory reports of certain diseases by
clinicians for health care providers and/or
facilities
 Reports by laboratories
 Sentinel surveillance systems
 Periodic prevalence surveys
 Vital records (births and deaths)
 Secondary analysis of datasets collected for
other purposes
Types of Surveillance
 Routine reporting systems
 Sentinel reporting system
 Case/outbreak investigation
 Special studies for specific health problems
Types of Surveillance
Passive Surveillance:
Surveillance data is typically obtained through

health provider initiated reports such as

notification forms filled by nurses of health
department, solicited reports
Good for conditions that have clear

symptomatology (measles)
Less costly than active surveillance
Types of Surveillance
 Passive Surveillance:
 Primary advantage is efficiency: simple and requires relatively few resources
 Disadvantage is possibility of incomplete data due to underreporting
 Majority of public health surveillance systems are passive
 Types of Surveillance
 Passive Surveillance:
Types of Surveillance
Active Surveillance:
Used for disease which can be easily missed

(malaria)
It reminds health worker to be more on the

lookout for these conditions

It need laboratory confirmation because of its

non specific clinical syndrome

Types of Surveillance
Active Surveillance:
Types of Surveillance
Active Surveillance:
 Requires more resources than passive surveillance
 Useful when important to identify all cases
 Example: between 2002 and 2005, active surveillance
used to detect adverse events associated with smallpox
vaccine.
Types of Surveillance
Sentinel Surveillance:
Uses data from a few selected sites rather than

data from all sites (clinic)

 Since it is from selected sites it provide

accurate and more complete data on the sentinel

population
More quick, more reliable and less costly

Most of them are passive surveillance

Types of Surveillance
Outbreak Surveillance:
Are undertaken to establish the source and cause

of the outbreak.
AIM:

 Quick control of the outbreak with targeted interventions

 Vaccine efficacy
 Age specific attack rate
 Case fatality
Uses of Surveillance Data
 Priority setting and planning
 Resource mobilization and allocation
 Prediction and early detection of epidemics
 Early and adequate detection and response
 Monitoring and evaluation of intervention programs
 Identify high risk groups
 Increase knowledge of vectors, dynamics of transmission
Establishing a surveillance
system
 Define by the objective
 Who needs it?
 How it will be used?
 Case Definition
 Sensitive to identify people who need public health attention
 Specific to avoid unnecessary diversion of attention
 Flow of information
 Reporters
 Data collection instruments
 Timing/Chronology/Synchronicity
 Aggregation of data
 Transmission
Key elements of surveillance
systems (WHO, 1999)
 All surveillance systems involve six elements :
 Detection and notification of health event
 Investigation and confirmation (epidemiological,
clinical laboratory
 Collection of data
 Analysis and interpretation of data
 Feedback and dissemination of results
 Response – a link in public health program,
specifically actions for prevention and control
What are the consideration in
planning public health surveillance
 Setting priorities: Public Health Importance
 Measures of the disease’s seriousness for the
individual,
 its current burden on society
 the potential burden on society (which involves
the issue of communicability and the potential for
epidemic spread), and
 preventability. The country’s capacity to respond
with necessary public health actions for disease
prevention and control
Criteria for Identifying High-Priority
Health Events for Surveillance
 Frequency
 Incidence
 Prevalence
 Mortality

 Severity
 Case fatality ratio
 Hospitalization rate
 Disability rate
 Years of potential life lost
 Quality-adjusted life years lost
Criteria for Identifying High-Priority
Health Events for Surveillance
 Cost
 Direct and Indirect cost
 Preventability
 Communicability
 Public Interest
Setting goals and objectives
 Estimating incidence
 measuring trends
 Identifying cases of intervention
 developing effective and control programs, and
 evaluating interventions
Case Definition
 A ‘case’ can depend on clinical
diagnosis, laboratory results,
demographic information, or any other
agreed on attribute
 must be standardized
 be more or less restrictive than criteria
used for clinical diagnosis
Case Definition of dengue
fever
 Clinical description – an acute febrile
illness of 2-7 days duration with 2 or
more of the following; headache, retro-
orbital pain, myalgia, arthralgia, rash,
hemorrhagic manifestations, leukopenia
Laboratory criteria for
diagnosis of dengue fever
 one of more of the following;
 Isolation of the dengue virus from
serum, plasma, leukocytes, or
autopsy samples
 Demonstration of a fourfold or greater
change in reciprocal IgG or IgM
antibody titers to one or more dengue
virus antigens in paired serum
samples
Laboratory criteria for
diagnosis of dengue fever
 demonstration of dengue virus in
autopsy tissue by
immunochemistry,
immunofluorescence or in serum
samples by EIA
 detection of viral genomic
sequences in autopsy tissue, serum
or CSF samples by PCR.
 Recommended case classification
 Suspected: A case compatible with the clinical
description
 Probable: A case compatible with the clinical
description with one or more of the following:
 Supportive serology (reciprocal HI antibody titer greater than
or equal to 1280, comparable IgG EIA titer or positive antibody
test in late acute convalescent-phase serum specimen
 occurrence at same location and time as other conformed
cases of dengue fever

 Confirmed: A case compatible with the clinical description, laboratory

confirmed
Criteria for Disease Selection
 Does the disease have a high disease impact (morbidity,
disability, or mortality)
 Does it have a significant epidemic potential (epidemic, cholera,
meningitis or measles)
 Is it specific target of a national, regional, or international
control program
 Will the information collected lead to a significant public health
action ( such as immunization campaign, other specific control
measures, or international reporting)
Sources and Types of Data
Relevant to Disease Surveillance
 Mortality reports
 Morbidity reports
 Reports of laboratory utilization
 Reports of individual case investigation
 Reports of epidemic investigations
 Special surveys (serologic surveys)
 Information on animal reservoir and vectors
 Demographic data
 Environmental data
 Biologics and drug distribution
 News media
 Factors leading to usefulness or
ineffectiveness of Surveillance systems
Factor/Element Effective Ineffective
System System

No of conditions Fewer Too many

Amount of information per case Lean Too much

Burden on reporter (reporting form) Lean High

Decision maker’s interest in High Low

surveillance data
Goals for surveillance Clear and supported May never
have been
clear

Usefulness of data to local collectors High Low

HIV risk factor surveillance
Measles Surveillance
Influenza Surveillance
(morbidity)
Influenza Surveillance
(mortality)
Influenza Surveillance
(laboratory)
What is NESSS?
 National Epidemic Sentinel Surveillance
System
 is a hospital-based information system that
monitors the occurrence if 14 infectious
disease with outbreak potential
 Serves as a supplemental information system
of the Department of Health
Objective of NESSS?
 To provide early warning on occurrence of
outbreaks
 To provide program managers, policy makers
and public administrators rapid, accurate and
timely information so that preventive and
control measures can be instituted .
Uses of NESSS?
 Detect and identify outbreaks of disease
 Observe disease trends relevant for program
planning, implementation and evaluation
 Identify specific high risk groups for
appropriate allocation of resources and
manpower
Diseases under surveillance
(NESSS)
 Laboratory Diagnosed
 Cholera
 Hepatitis A
 Hepatitis B
 Malaria
 Typhoid Fever
Diseases under surveillance
(NESSS)
 Clinically Diagnosed



Dengue Fever/DHF
Diphtheria
 Measles
 Meningococcal Disease
 Neonatal Tetanus
 Pertussis
 Rabies
 Leptospirosis

Acute Flaccid Paralysis (Poliomyelitis)
 Why Is Surveillance
Important?
 Surveillance information has many uses:
 Monitoring disease trends
 Describing natural history of diseases
 Identifying epidemics or new syndromes
 Monitoring changes in infectious agents
 Identifying areas for research
 Evaluating hypotheses
 Planning public health policy
 Evaluating public health policy/interventions
Why Is Surveillance
Important?
 Examples of uses of surveillance data:
 Evaluating impact of national vaccination
campaigns
 Identifying AIDS when unknown syndrome
 Estimating impact of AIDS on US health care
system in 1990s (using mathematical models
based on surveillance data)
 Identifying outbreaks of rubella and congenital
rubella among Amish and Mennonite communities
in 6 states in 1990 and 1991 (3)
 Monitoring obesity, physical activity,
other indicators for chronic diseases
How to Conduct Surveillance
 Surveillance data allow description and
comparison of patterns of disease by
person, place, and time
 Several ways to describe and compare
patterns, from straightforward
presentations to statistically complex
analyses
How to Conduct Surveillance:
Person
 When available, demographic characteristics
such as gender, age, race/ethnicity,
occupation, education level, socio-economic
status, sexual orientation, immunization
status can reveal disease trends
 Example: looking at Streptococcus pneumoniae, a
common cause of community-acquired pneumonia
and bacterial meningitis, examining distribution of
cases by race provides important information
about burden of disease in different populations
How to Conduct Surveillance:
Person – Numbers and Rates
 Table 1 shows data
collected on
Streptococcus
pneumoniae from CDC
Emerging Infections
Program Network, a
surveillance program
that collects data from
multiple counties in 10
US states (4)
How to Conduct Surveillance:
Person – Numbers and Rates
 Data show majority of
cases reported among
whites
 Can draw only limited
conclusions because race
not recorded for 684 cases
(15%)
 Shows only number of
reported cases, not rate
 Total number of
individuals by race needed
to determine if there is a
disproportionate burden of
disease among races
How to Conduct Surveillance:
Person – Numbers and Rates
 Table 2 shows
same data with
2006 population
estimates of total
number of persons
in each racial
category used to
calculate disease
rates (4)
How to Conduct Surveillance:
Person – Numbers and Rates
 While Table 1 showed
that whites had the
highest number of cases,
Table 2 indicates that
the rate of disease was
highest among blacks
 Using rates, stratifying
by race provides
information about
disease burden in
different populations
that would not be
apparent from total case
numbers
More on Rates
 Rates—A rate is “an expression of the
frequency with which an event occurs in a
defined population”
 Using rates rather than raw numbers is
essential to compare different classes of
persons or populations at different times or
places. (5)

Rate = number of events in a specified period

average population during the period
How to Conduct Surveillance:
Place
 Best to characterize cases by place of exposure
rather than by place at which cases reported
 The two may differ and place of exposure is more
relevant to epidemiology of a disease
 Example: travelers on a cruise ship exposed to a disease
just prior to disembarking but become symptomatic and are
diagnosed after return to various home locations
 Example: person exposed to disease in small rural town but
referred to tertiary care center 100 miles away where
disease is diagnosed and reported
How to Conduct Surveillance:
Place – Presenting Data
 Data by geographic location can be presented
in a table
 Also helpful to use maps to facilitate
recognition of spatial associations in data
 See FOCUS Volume 5, Issue 2: Mapping for
Surveillance and Outbreak Investigation for
discussion of maps and visual presentation of
information
 Inferential analysis can also be done using
multilevel modeling, other statistical methods
How to Conduct Surveillance:
Place – Modeling Resources
 Modeling of surveillance data by place is
beyond scope of this issue
 Resources for further information:
 Centers for Disease Control and Prevention.
Resources for creating public health maps.
http://www.cdc.gov/epiinfo/maps.htm. Updated
August 14, 2008. Accessed August 22, 2008.
 Clarke KC, McLafferty SL, Tempalski BJ. On
epidemiology and geographic information
systems: A review and discussion of future
directions. Emerg Infect Dis. 1996; 2(2):85-92.
How to Conduct Surveillance:
Place – Spot Maps
 Spot maps: maps on which a dot or symbol marks a
case of disease
 Made by indicating exposure locations of reported
cases of disease on hard copy map with pins or
colored pen
 Or with geographic information systems (GIS)
 Computer programs designed for storing, manipulating,
analyzing, and displaying data in a geographic context
 Very useful for mapping surveillance data by place
 Epi Map (part of Epi Info™) can be downloaded for free at
http://www.cdc.gov/epiinfo to assist with map making
How to Conduct Surveillance:
Place – Spot Maps
 Example: spot map used to
show geographic spread of
cases in 1995 outbreak of
toxoplasmosis thought to be
associated with a municipal
water system in British
Columbia, Canada (5)
 Spot maps show geographic
distribution of cases but not
population size at each
location, so should not be
used to assess disease risk
How to Conduct Surveillance:
Time
 Compare number of cases reported in time
period of interest (weeks, months, years) to
number of cases reported during similar
historical period
 Usually a delay (sometimes months to years)
between disease onset and date when
disease is reported, so preferable to use date
of onset, if available, rather than date of
report
How to Conduct Surveillance:
Time – Line Graphs
 Especially helpful for examining data not
likely to have much short term variation
 Example: there is limited variation in number of
AIDS cases reported each month
 Provide valuable qualitative information;
disease outbreaks often obvious from visual
inspection of data, may not require a
quantitative analysis
How to Conduct Surveillance:
Time – Line Graphs
 Example of line graph
using fabricated data:
reported cases of
Salmonella
typhimurium for 2-year
time intervals from
1974 to 2002
 Spike in 1994 indicating
outbreak of S.
typhimurium obvious
without quantitative
analysis
How to Conduct Surveillance:
Time – Incidence Rates
 May use line graph to plot incidence rates
 Incidence rate is number of new cases that occur
during a specified time interval in a population at risk
for developing the disease
 Number of new cases may be used as a proxy for overall
disease occurrence
 Value often multiplied by 1,000 or 100,000 to improve
interpretability
 Reporting incidence rates rather than numbers
particularly important if population has changed in
size or characteristics
 Example: addition of towns to a surveillance region has
increased population size, or influx of migrant workers has
significantly changed the demographics
Data Presentation
 Surveillance data must be presented in way
that is easy to understand and interpret
 Many ways to display surveillance data: (3)
 Line graphs for displaying data by time
 Maps for presenting data in geographic context
 Graphical displays such as histograms, frequency
polygons, box plots, scatter diagrams, bar charts,
pie charts, or stem-and-leaf displays
 Spot or chloropleth maps
 Single/multivariable tables
Data Presentation
 The choice of a particular graph or table
depends on type of data, but presentation
should be simple and easy to follow
 Should provide all information necessary to
interpret the figure without referring to text
 Include concise title that describes subject or
disease, time, place (when relevant)
 Define any abbreviations or symbols
 Note any data exclusions (3)
Data Presentation
 Additional
display
guidelines
for tables
and graphs