Public Health Surveillance

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 Contents
• Concept and definition
• Purpose and uses
• Planning for surveillance
• Types and Methods
• Analysis of Surveillance data
• Dissemination
• Evaluation

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 Surveillance concept
“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, and the regular
dissemination of these data to] all who
need to know" (Langmuir, 1963)
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 Definition of Surveillance
“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. The final link in
the surveillance chain is the application of
these data to prevention and control. A
surveillance system includes a functional
capacity for data collection, analysis, and
dissemination linked to public health
programs." (CDC,1986)
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 The key elements of any definition
of surveillance are:
• ongoing (as opposed to a one-time survey)
• systematic (standardized, to facilitate
comparisons across space and time)
• collection
• analysis
• interpretation
• dissemination (to those who need to know to
take action, and to those who provide reports)
• link to action (surveillance is sometimes
called
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"information for action")
 What Surveillance Is?
• Systematic, Health action
ongoing…
• investigation
– Collection
• control
– Analysis
– Interpretation • prevention
– Dissemination
• …of health outcome
data
• – Link to public health
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action
 Purpose of Surveillance
1. To assess public health status, to define
public health priorities, to evaluate
programs, and to stimulate research.
2. Tells us where the problems are, who is
affected, and where the programmatic and
prevention activities should be directed.

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 Uses of Surveillance Data
• Quantitative estimates of the magnitude of
a health problem including sudden or long-
term changes in trends and patterns
• Portrayal of the natural history of disease
(clinical spectrum, epidemiology)
• Detection of epidemics
• Documentation of distribution and spread
of a health event
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Uses … cont..
• Facilitation of epidemiologic and laboratory
research – Hypothesis testing
• Evaluating, control & prevention measures
• Monitoring changes in infectious agents
and host factors
• Detecting changes in health practice
• Facilitate planning

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 Planning a Surveillance System
• Establish objectives
• Develop case definitions
• Determine data source or data collection
mechanism
• Field test methods
• Develop and test analytic approach
• Develop dissemination mechanism
• Assure use of analysis and interpretation
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 Factors determining disease
importance
• Incidence and Prevalence
• Mortality: Case Mortality Rate and
Case Fatality Rate
• Disabilities associated with the
disease.
• Epidemic potentiality
• International Health Regulations
• Relative Importance
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 Priority charts
Diseases are rated according to:
• Morbidity, Mortality and Disability
• The technical feasibility of possible
interventions
• Economic feasibility of the possible
interventions
• Public response for intervention

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 Case definition
• Important to clearly define condition
• Ensures same criteria are used by all
• Makes the data more comparable
• Include person, place, time
• May define suspected and confirmed
cases
• May include symptoms, lab values, time
period, population as appropriate
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 Major Steps
• An assessment of the relative importance
of each disease
• An assessment of the feasibility of the
available principle control measures
• Establishment of priorities based on the
two assessments

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 Types
• Passive surveillance = health care
providers, hospitals, and labs send reports
to the health department based on a set of
rules and regulations.
• Active surveillance = health department
staff call or visit health care providers on a
regular basis (e.g., weekly) to solicit case
reports.

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 Most common surveillance
methods
A. Routine reporting system
B. Sentinel reporting system
C. Surveys and special studies
D. Case and outbreak investigation

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 A. Routine reporting system
A1: Data Sources
• Vital Statistics
• Notifiable Diseases
• Registries
• Sentinel Surveillance
• Syndromic Surveillance
• Surveys
• Administrative Data

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 Vital Statistics
• Live Births
• Deaths
• Fetal Deaths
• Marriages
• Divorces
• Induced Terminations of Pregnancy
• Infant Mortality (link birth and death data)

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 A2: Uses of Vital Statistics Data
• Monitoring long-term trends
• Identifying differences in health status
within racial or other population subgroups
• Assessing differences by geographic area
• Monitoring deaths that are preventable
• Generating hypotheses about causation
• Monitoring progress toward improved
health of the population; health-planning
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 A3: Vital Records: Coding and
Calculating
• ICD-9 historically, now ICD-10
• Infant mortality - need number of live
births for denominator in calculating
rates
• Other death rates - use total
population in rate calculations.
• Crude and adjusted (standardized)
rates used.
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 A4: Quality of Vital Stat Depends on:

• Care taken by health care providers in

ascertaining cause of death and other
factors
• Accuracy of coding (difficult for injuries)
• Relevance of existing codes for the
condition being recorded
• Accuracy of population estimates
• Problems - don’t know onset, can’t see
effect of diseases that don’t lead to death
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 A5. Routine reporting system
Advantages and Disadvantages
Advantages:
• Inexpensive and efficient
• Data is comprehensive for health care
activities
• Useful for comparison through time and for
different localities and regions
Disadvantages:
• Incomplete reporting
• Variation between health care providers
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 B. Sentinel Systems
• To gather timely public health information
in a relatively inexpensive manner.
• Cannot derive precise estimates of
prevalence or incidence in the population.
• Sentinel Health Events
• Sentinel Sites
• Sentinel Providers

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 B1: Sentinel Health Events
• A condition whose occurrence serves as a
warning signal.
• Particularly useful for occupational
exposures: Silicosis, occupational asthma,
pesticide, poisoning, lead poisoning,
carpal tunnel syndrome.
• Cases trigger intervention activities.

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 B2: Sentinel Sites or Providers
• Surveillance at certain hospitals, clinics, or
physician practices.
• Sentinel Sites - monitor conditions in
subgroups that may be more vulnerable –
e.g., drug clinic, STD clinic, MCH clinic
• Sentinel Providers - monitor activity in
ambulatory care settings.
– For diseases that are not reportable
– For influenza
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 2. Sentinel reporting system
Advantages and Disadvantages
Advantages:
• More consistent picture on illness
• Demonstrate accuracy of the reporting system
• Motivation of staff towards accuracy and
completeness
Disadvantages:
• Not representative of the entire population
• Lack of statistically significant differences
• Invalid if population changes
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 C. Surveys
• If done continually or periodically, can
monitor risk factors and changes in
prevalence over time.
• Can also assess knowledge, attitudes
• People usually queried only once and not
monitored on an individual basis after that
From questionnaires, interviews (in person
or telephone), or record review.
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 Analysis of Surveillance Data
• Descriptive epidemiology
(Person, place, time)
• Incidence and Prevalence
(Rates: crude, specific, standardized)
• Trends and seasonality
• Geographic clustering (maps)

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 Surveillance information
All surveillance instruments should include the
following categories of information:
• Patient identifying information (name, address,
phone number) - allows call backs, check for
duplicate records.
• Demographic information (date of birth or age,
sex, race) - allows characterization of
populations at risk
• Clinical information (date of onset,
signs/symptoms, lab results, met case
definition?, hospitalized, died?) - allows
verification of case definition, characterization of
spectrum and course of disease and impact on
resources.
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• Risk factors (occupation, household contacts,
travel, immunization status, possible exposures
such as food, water, swimming, animals) - to help
generate or evaluate hypotheses during an
investigation, targeting of prevention and/or control
measures
• Reporter identifying information (name,
address, phone number, date of report) - allows
follow-up and feedback
Some surveillance instruments also include:
• Follow-up actions
• Contacts, i.e., whom the case may have exposed
(STDs, rabies, et al.)
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A true increase may result from:
• increase in the size of the susceptible
population (births, immigration, etc.)
• low vaccination coverage
• vaccine failure (primary = no immunity
induced; secondary = waning immunity)
• change in the agent (virulent strain or
antigenic shift away from vaccine type)
• vaccine-associated polio
(Ref: CDC. Outbreak of poliomyelitis—Dominican Republic and Haiti, 2000. MMWR
2000;49:1094,1103.)

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 Artifactual reasons include:
• changes in local reporting procedures (e.g., easier
reporting procedure like active rather than passive)
• changes in case definition (cf: AIDS)
• increased interest because of local or national
awareness
• improvements in diagnostic procedures
• new health care workers or facilities - may see more
referred cases, may make the diagnosis more often,
may report more reliably
• outbreak of similar disease, misdiagnosed as disease
of interest
• laboratory error
• batch reporting
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 Dissemination
Surveillance data should be distributed to "those who
need to know." That includes:
• Those who provide the data - health workers,
hospitals, labs, etc.
• Those who are responsible for acting on the data -
public health program managers, field workers,
policy makers
• Those with oversight responsibility - Minister and
staff, perhaps donor agencies
• Others who are interested - village elders, public
health (other districts, WHO, etc.), special interest
33groups, sometimes the public at large.
 Dissemination methods
Information could be disseminated by:
• newsletter
• annual report
• press releases
• scientific journal articles
• scientific (and public) meetings
• village presentations
Recently, internet web pages are excellent
rapid easy way for dissemination.
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 Evaluation
• Did the system generate needed answers
to problems?
• Was the information timely?
• Was it useful for planners, researchers,
etc?
• How was the information used?
• Was it worth the effort?
• What can be done to make it better?
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Evaluating Surveillance Systems
• System objectives and usefulness
– Actions taken as a result of the data.
– Does the system do what it’s supposed to do?
• Operation of the system
– who is reporting? to whom? what information is
collected? how is information stored? Who
analyzes the data? what are the findings? How
often are reports disseminated? to whom? etc.
• Cost
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 Evaluation of Important
attributes to surveillance system
• Simplicity - the ease of operation of the system
as a whole and each of its components
• Flexibility - ability to accommodate changes in
operating conditions or information needs
• Data Quality - completeness and validity of the
data collected and recorded
• Acceptability - willingness of individuals and
organizations to participate in the system
• Sensitivity - ability to detect the cases or health
events or outbreaks it is intended to detect•

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Attributes …. Cont.

Predictive Value Positive - mostly affected by the

system's specificity, PVP is the proportion of
reported cases (or outbreaks) which truly are cases (or
outbreaks)
• Representativeness - extent to which the system
accurately portrays the incidence of the health
event in a population by time, place, and person
• Timeliness - availability of data in time for appropriate
action
• Stability - reliability and availability of the system
(operates properly without failure).

Ref: CDC. Updated guidelines for evaluating public health surveillance systems: recommendations
from the guidelines working group. MMWR 2001;50(No. RR-13):11-24

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 “Good surveillance does not
necessarily ensure the taking of
right decisions, but it reduces
the chances of wrong ones.”
Alexander D. Langmuir
NEJM 1963; 268:182-191

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