Training for mid-level managers (MLM)

8. Making disease surveillance work

Surveillance :
What and why ?

Types of surveillance

Setting up and
monitoring

Reporting

Analysis and action

Feedback

Immunization, Vaccines and Biologicals

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Training for mid-level managers (MLM). Module 8: making disease surveillance work
ISBN 978-92-4-001577-7 (electronic version)
ISBN 978-92-4-001578-4 (print version)
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 >

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This new series of modules on immunization training for mid-level managers
replaces the version published in 1991. As there have been many changes in
immunization since that time, these modules have been designed to provide
immunization managers with up-to-date technical information and explain how
to recognize management and technical problems and to take corrective action
and how to make the best use of resources.

More and more new, life-saving vaccines are becoming available, yet the
introduction of a new vaccine does not necessarily require a separate plan and
separate training. This new series for mid-level managers integrates training for
new vaccine introduction into each subject addressed by the modules. In this
way, introduction of new vaccines is put into its day-to-day context as part of the
comprehensive range of activities required to improve immunization systems.

In the context of these modules, mid-level managers are assumed to work in

secondary administrative levels, such as a province ; however, the modules can
also be used at national level. For district managers (third administrative level),
a publication on ‘immunization in practice’ 1 is widely available. As it contains a
large amount of technical detail, it is also recommended for mid-level managers
courses.

In writing these modules, the authors tried to include essential topics for mid-level
managers, while keeping the modules brief and easy to use. They are intended to
complement other published materials and guidelines, some of which are referred
to in the text. Many more documents are available on the CD-ROM which
accompanies this series. Each module is organized in a series of steps, in which
technical information is followed by learning activities. Some knowledge and
experience are needed to complete the learning activities, but even new readers
should be imaginative and constructive in making responses. Facilitators should
also be aware that the responses depend on the national context. Thus, there
are no absolutely right or wrong answers, and the series does not set down new
‘policies’ or ‘rules’. The authors hope that the readers of these modules will find
them informative, easy to read and an enjoyable learning experience.

Modules in the mid-level managers series

Module 1 : Cold chain, vaccines and safe-injection equipment management
Module 2 : Partnering with communities
Module 3 : Immunization safety
Module 4 : Supportive supervision
Module 5 : Monitoring the immunization system
Module 6 : Making a comprehensive annual national immunization plan and
budget
Module 7 : The EPI coverage survey
Module 8 : Making disease surveillance work

1
Immunization in practice : A practical guide for health staff. Geneva, World Health Organization, 2004

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This new series of modules on immunization training for mid-level managers
is the result of team work between a large number of partners including the
Centers for Disease Control and Prevention (CDC), IMMUNIZATIONbasics,
Program for Appropriate Technology in Health (PATH), United Nations Children’s
Fund (UNICEF), United States Agency for International Development (USAID)
and the World Health Organization (WHO). The authors are especially grateful to
the consultants from the University of South Australia who have made a major
contribution to the development of the modules.

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Introduction to the series I
Modules in the mid-level managers series I
Acknowledgements II
Introduction to Module 8 1
Purpose of this module 1
1. Surveillance : What and why ? 2
1.1 What is disease surveillance ? 2
1.2 Why is disease surveillance necessary ? 2
1.3 Definitions of control, elimination and eradication 3
2. Types of surveillance 4
2.1 Passive surveillance 4
2.2 Sentinel surveillance 5
2.3 Active surveillance 5
3. Setting up and monitoring surveillance 8
3.1 Setting up passive surveillance 8
3.2 Setting up sentinel surveillance 9
3.3 Setting up active surveillance 10
3.4 Collecting information for a surveillance system 12
3.5 Monitoring surveillance quality 13
3.6 Case Confirmation 17
4. Reporting 20
4.1 Summarizing and reporting data 20
4.2 Frequency 20
5. Analysis and action 24
5.1 Determining patterns 24
Is there a pattern over time ? 24
Is there a pattern over place ? 26
Is there a pattern by person ? 26
5.2 Taking action on surveillance reports and data analysis 27
6. Feedback 30
6.1 To reporting sites 30
6.2 To the community 30
6.3 Calculating vaccine effectiveness 31
Annex 1 : Bibliography 34
Annex 2 : Surveillance and response activities for selected
vaccine-preventable diseases 35
Annex 3 : Five steps in conducting an active surveillance visit 36
Annex 4 : Sample reporting forms 37
Annex 5 : Impact of the new International Health Regulations on
surveillance of vaccine-preventable diseases in your country 40
Annex 6 : Outbreak investigation 41
6.1 Introduction 41
6.2 Steps in an outbreak investigation 41
Annex 7 : Revision exercises 44

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Are reports of vaccine-preventable diseases sent to your province office every
month ? Do your health staff understand the value and relevance of the
information that they send you ? If you suspect that the surveillance information
is incomplete or inadequate, or if surveillance needs to be enhanced to include
additional diseases, how can you improve the surveillance system to meet
these needs ?

This module describes various well-established methods of conducting and

using surveillance of vaccine-preventable diseases. Various steps common to
many diseases are explained, and in addition there are specific details on a number
of common vaccine-preventable diseases. There is also a section describing the
principal activities for outbreak response.

The purpose of this module is to explain in practical terms the basic concepts of
surveillance and how to manage a surveillance system for vaccine-preventable
diseases. It is hoped that the participant, after reading this module and discussing
the concepts with the facilitator, will have a fair idea of how to start, run and monitor
a surveillance system.

This module is organized into the following sections :

Surveillance: Types of Setting up and

> > > Reporting >
What and why? surveillance monitoring

Analysis
> Feedback
and action

Many excellent textbooks, guidelines and practical exercises are available

on disease surveillance, clinical details of various diseases and laboratory
techniques. A list of useful references is given in Annex 1, and some key
resources are listed in subsequent annexes.

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Surveillance is data collection for action. The mere collection and compilation
of disease-related data without analysing them and taking appropriate action is
not surveillance. Disease surveillance is the systematic collection, analysis and
dissemination of data on diseases of public health importance so that appropriate
action can be taken to either prevent or stop further spread of disease. It guides
disease control activities and measures the impact of immunization services.

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Disease surveillance is used to :
s predict or detect disease outbreaks with a view to investigation and containment;
s IDENTIFY HIGH RISK POPULATIONS AND AREAS REQUIRING SPECIAL ATTENTION 
s MONITOR IMPACT AND PROGRESS TOWARDS DISEASE ERADICATION ELIMINATION AND
control ;
s identify areas in which system performance is poor, so that corrective measures
can be taken ;
s DETERMINE THE FREQUENCY OF OCCURRENCE OF A DISEASE IN A COMMUNITY AND THE
burden of disease ;
s monitor programme effectiveness by documenting short- and long-term
effects of immunization on disease burden and epidemiology ;
s IDENTIFY CIRCULATING STRAINS INCLUDING SEROTYPES GENOTYPES AND SUBTYPES

The type of surveillance for a specific vaccine-preventable disease depends on

the attributes of the disease and the objectives of the disease control programme
––control, elimination or eradication (see section 1.3).

These factors direct the surveillance activities to be implemented. Table 8.1 lists
the vaccine-preventable diseases and their associated surveillance activities.
You will see that some diseases have more than one disease control objective,
according to national and regional goals.

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Vaccine-preventable Disease Surveillance activity

disease* control Find all cases Monitor trends, Provide evidence Identify circulating
objective or chains of predict and on disease burden, strains
transmission detect outbreaks epidemiology
and identify at- of disease and
risk populations impact of
immunization
Diphtheria Control x
Haemophilus Control
x x
influenzae type b
Hepatitis B Control x x
Influenza Control x x x
Japanese encephalitis Control x x
Measles Control x x
Measles Elimination x x
Meningococcal disease Control x x
Neonatal tetanus Elimination x
Pertussis Control x
Pneumococcal disease Control x x
Poliomyelitis Eradication x x
Rotavirus Control x
Rubella or congenital Control
x
rubella syndrome
Rubella or congenital Elimination
x x
rubella syndrome
Yellow fever Control x
*The disease control objectives, case definitions and data requirements for each vaccine-preventable disease are given in Annex 2.

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s Control : The reduction of disease incidence, prevalence, morbidity or mortality
to a level that is locally acceptable as a result of deliberate efforts. Continued
intervention measures are required to maintain the reduction. Example :
diphtheria, pertussis.
s Elimination : Reduction to zero of the incidence of a specified disease in a
defined geographical area as a result of deliberate efforts. Continued intervention
measures are required. Example : polio in certain continents. (The elimination of
neonatal tetanus is defined differently.)
s Eradication: Cockburn’s definition1 is “Eradication is the extinction of the pathogen
that causes the infectious disease in question; so long as a single member of the
species survives, then eradication has not been accomplished“. In more practical
terms, eradication is the reduction to zero of the worldwide incidence of infection
caused by a specific agent, the complete interruption of transmission and the
extinction of the causative agent so that it no longer exists in the environment. As
a result, intervention measures are no longer needed. Example: smallpox.

1
Cockburn TA. Eradication of infectious diseases. Science, 1996, 133 :1050–1058.

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The type of surveillance for a particular disease depends on the attributes of that
disease and the objectives of the immunization programme. For example, when
the objective of the programme is control of measles and surveillance for measles
is started, the number of cases is high, and it is important to know where the
cases are. Therefore, a system that covers the entire country is needed, but the
details of individual cases are not. In contrast, when the number of measles cases
is reduced and the programme objectives change to elimination, investigation of
individual cases and transmission chains will become necessary.

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Regular reporting of disease data by all institutions that see patients (or test
specimens) and are part of a reporting network is called passive surveillance.
There is no active search for cases. It involves passive notification by surveillance
sites and reports are generated and sent by local staff.

A passive surveillance system relies on the cooperation of health-care providers —

laboratories, hospitals, health facilities and private practitioners — to report the
occurrence of a vaccine-preventable disease to a higher administrative level. Once
the data have been received, they must be compiled and then analysed to monitor
disease patterns and identify possible outbreaks. Passive surveillance involves the
regular collection and reporting of surveillance data and is the commonest method
used to detect vaccine-preventable diseases. In most countries with a passive
surveillance system, every health facility is required to send a monthly (sometimes
weekly/daily) report of all cases of vaccine-preventable disease (and sometimes
other diseases of interest) on a standard form.

Passive surveillance is less expensive than other surveillance strategies and covers
wide areas (whole countries or provinces); however, because it relies on an extensive
network of health workers, it can be difficult to ensure completeness and timeliness
of data.

Some countries might not have the capacity or resources to identify all cases
of a disease, either because the diagnosis of the disease requires specialized
clinical skills or because laboratory resources are not available throughout the
country. Under these circumstances, passive surveillance can be adapted in a
number of ways, depending on the completeness and quality of data required,
financial constraints and the availability of specialist skills and services.

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A sentinel surveillance system is used when high-quality data are needed about
a particular disease that cannot be obtained through a passive system. Selected
reporting units, with a high probability of seeing cases of the disease in question,
good laboratory facilities and experienced well-qualified staff, identify and notify
on certain diseases. Whereas most passive surveillance systems receive data
from as many health workers or health facilities as possible, a sentinel system
deliberately involves only a limited network of carefully selected reporting sites. For
example, a network of large hospitals might be used to collect high-quality data on
various diseases and their causative organisms, such as invasive bacterial disease
caused by Haemophilus influenzae type b, meningococcus or pneumococcus.

Data collected in a well-designed sentinel system can be used to signal trends,

identify outbreaks and monitor the burden of disease in a community, providing
a rapid, economical alternative to other surveillance methods. Because sentinel
surveillance is conducted only in selected locations, however, it may not be as
effective for detecting rare diseases or diseases that occur outside the catchment
areas of the sentinel sites.

The following criteria should be considered in selecting a sentinel health facility

(usually a general or infectious disease hospital) :
s )T SHOULD BE WILLING TO PARTICIPATE
s )T SERVES A RELATIVELY LARGE POPULATION THAT HAS EASY ACCESS TO IT
s )T HAS MEDICAL STAFF SUFlCIENTLY SPECIALIZED TO DIAGNOSE TREAT AND REPORT CASES
of the disease under surveillance.
s )T HAS A HIGH QUALITY DIAGNOSTIC LABORATORY

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Active surveillance involves visiting health facilities, talking to health-care providers
and reviewing medical records to identify suspected cases of disease under
surveillance. Designated active surveillance staff regularly visit health facilities in
person to search for suspected cases among persons who might have attended
the facility. It involves physical review of medical records and registers, interviews
with health workers and visits to relevant outpatient clinics and hospital wards.
When a case is found, the active surveillance staff investigate it, document clinical
and epidemiological data, arrange to send appropriate laboratory specimens and
report the information rapidly, according to national policy. This method is usually
used when a disease is targeted for eradication or elimination, when every possible
case must be found and investigated. It is also used for outbreak investigations.

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Active surveillance is more difficult to set up and expensive to conduct. It does

not replace passive surveillance but complements it. If conducted regularly it
has the following advantages :
s helps to improve the timeliness and accuracy of case detection and reporting ;
s ENABLES RAPID CASE INVESTIGATION INCLUDING TAKING LABORATORY SPECIMENS 
s IS CLOSELY LINKED TO THE LABORATORY SYSTEM THROUGH INDIVIDUAL CASE IDENTIlCATION
s ENABLES TIMELY ACTION TO BE TAKEN IN RESPONSE TO THE DETECTED CASE

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The term ‘active search’ is used to describe searches for cases in the community.
There is also ‘retrospective record search’, which is used to search hospital and clinic
records and is used for diseases under elimination. This is sometimes (mistakenly)
also referred to as active search. In active search, health staff usually go door-to-door
asking about cases of the disease in question. Active search may also be conducted
where an outbreak is ongoing (such as commercial centres, working areas, schools,
universities etc.). This is a very resource-intensive way of finding cases, requiring
many people and large amounts of money, and is used only in certain situations,
e.g. during outbreaks to locate unreported cases and during polio immunization
campaigns to find cases of acute flaccid paralysis.

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Type of surveillance
Nationwide routine/passive Sentinel surveillance Active surveillance
surveillance
Population under Whole country Cases seen and treated at All cases attending selected
surveillance selected health facilities health facilities
Outcome measures Cases and deaths Cases and deaths in selected Cases and deaths in selected
Incidence rates health facilities health facility

Trends in epidemiology Full case investigation with

details on each case
Advantages Can provide accurate rates Requires limited resources Can represent the whole
and data on burden if report- Can be managed easily country
ing is complete and supported Directs eradication or elimina-
by reliable laboratory results Can contribute to basic under-
standing of disease burden tion programmes
Can be expanded to include
additional diseases as
required
Rapid detection of outbreaks
Disadvantages Needs extensive clinical Cannot be used to calculate Resource-intensive
and laboratory capacity and incidence rates Requires dedicated staff,
resources Is not representative of the transport, management
Reporting is rarely complete whole country Heavy demands on data
and timely management
Heavy demands on data
management

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In consultation with the national programme manager, a list should be drawn up
of all health facilities (both public and private) and practitioners who are likely to
see cases of the disease. Most countries already have some form of passive
disease surveillance system ; however, these might have to be strengthened and
should be supervised regularly. The institutions and persons should be visited and
briefed about case definition, frequency of reporting, reporting format, deadlines
for each report and the address to which the report should be sent. They should be
instructed to send a periodic report even if no cases are seen during the reporting
period.

When no cases are seen, ‘zero reporting’ is used, with a ‘0’ in the report, also
known as negative reporting. This is important to ensure the completeness of
reporting for monitoring the quality of the surveillance system and gives provincial
and national authorities confidence that the surveillance system is operational,
even if no disease is identified. A simple table should be maintained to track the
completeness of reporting, such as in the example given below (in August of that
year).

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Reporting institution Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Hospital ‘A‘ 3 3 3 3 3 3 3
Health centre ‘B’ 3 3 3 3
Practitioner ‘X’ 3 3 3 3

It can be seen from this table that health centre ‘B’ did not send a report for
March, May or June and practitioner ‘X’ did not report for February, April and
July. Such missing reports should always be followed up, both to indicate that
someone is tracking the reports and to tell the institution how much and why
their report is important.

A similar table with dates (shown below) should be maintained to track whether
the reports came in within the agreed time limit. The reason for maintaining two
separate tables is that reports can be delayed ; in this example, for instance, health
centre ‘B’ sent the reports for February, April and July in August, and practitioner
‘X’ sent the reports for May and June in August. Such grossly delayed reports,
although received, serve no useful purpose. A time limit should be set beforehand
(e.g. the 15th of the next month), after which time reports should be considered
late. Another limit (e.g. the 25th of the next month) should be set after which
reports will be classified as missing.

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Reporting institution Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Hospital ‘A‘ 02 03 06 07 04 07 09
Feb Mar Apr May Jun Jul Aug
Health centre ‘B’ 15 08 08 08
Feb Aug Aug Aug
Practitioner ‘X’ 05 05 10 10
Feb Mar Aug Aug

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Sentinel surveillance is the collection and analysis of data by designated institutions
selected for their geographical location, medical specialty and ability to diagnose
and report data accurately. Generally, sentinel surveillance is useful for answering
specific epidemiological questions, but, because sentinel sites may not represent
the general population or the general incidence of the disease, they might be of
limited use for analysing national disease patterns and trends.

When it is not possible to set up a network of all possible sites or when detailed
information is needed for certain diseases, a list of large hospitals (public and
private) that are likely to see cases of the disease in question should be drawn
up, in consultation with the national programme manager. These institutions
should have the clinical and laboratory expertise to provide the necessary
information, for instance, for surveillance of Haemophilus influenzae type b
meningitis (laboratory needed) or congenital rubella syndrome (clinical expertise
needed). Sentinel surveillance provides useful indicators about, e.g. trends of
disease occurrence, case fatality rates and early information on outbreaks. They
do not provide information on the full extent of the disease, such as geographical
distribution and the total number of cases.

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System description Advantages Disadvantages

Limited catchment area Easy to collect data on individual Although less costly than population-
patients based surveillance, may still require
Comprises network of hospitals and significant investment in personnel
laboratories selected from among Less costly and less demanding on and resources
all hospitals and laboratories in the resources
surveillance area Data may be biased or skewed
Flexible system design
Usually includes largest hospitals in Data are not generalizable to the
the area Useful for documenting trends population of the area

Pre-evaluation needed to select ap- Allows routine monitoring of resist- Does not allow collection of data on
propriate sentinel sites ance to antibiotics incidence

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The steps in setting up sentinel surveillance are as follows :

1. Decide on the disease for which the system is being set up, and determine
its attributes, e.g. age group affected, geographical distribution, seasonality
and causative organism.
2. Decide the boundaries of the area within which the system is to be set up.
3. Enumerate all large, medium and small hospitals and private practitioners in
that area.
4. For each institution or practitioner, decide how likely it is that it will see cases
of the disease. Those with the highest likelihood should be included first,
usually including all large hospitals and/or reference core hospitals. Depending
on available resources, expand the network to include other hospitals and
practitioners.
5. Meet the decision-maker at each hospital and the practitioners to be included.
Their participation should be voluntary, and financial incentives are best avoided.
Non-financial incentives, such as attractive certificates printed on glossy paper
attesting that a hospital or clinic is a part of the network, often work well and
are sustainable.
6. In consultation with the staff of the hospital or the practitioner, decide on
a standard case definition, the need for laboratory support, reporting and
periodicity of reporting. Standard formats for case investigations, laboratory
investigations and periodic reports must be agreed upon and provided to the
participating units. The method of reporting—by mail, fax, e-mail—must be
decided in advance.
7. Identify and obtain the agreement of laboratories capable of processing
specimens and willing to take on the extra work. A smaller number of more
advanced ‘reference’ laboratories for doing additional testing would also be
needed. Determine the method and mechanisms for the flow of specimens.
8. Regular feedback in the form of tables summarizing the data on disease,
classification of cases and others is essential.
9. Tables to track the completeness and timeliness of reporting should be used for
sentinel reporting sites, as described in section 3.1 for passive surveillance.

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The following steps are involved in establishing an active surveillance system.
It requires personnel at the senior management level who will manage active
surveillance, train staff at various levels and help select the reporting sites.

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Surveillance officers will be the focal points responsible for visiting designated
active surveillance sites in the network, conducting core investigations and
making follow-up visits. These could be staff already engaged in related activities,
such as district immunization workers.

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The choice of active surveillance reporting sites depends on several factors,
including the disease under surveillance and the behaviour of the community
towards illness. The selection should be made in consultation with persons at
the senior management level, and they may include hospitals, clinics, private
practitioners and traditional healers.

The surveillance officer should make an effort to meet busy health-facility staff
personally to obtain their commitment, cooperation and continued involvement
in active surveillance. It is useful to conduct an introductory meeting at which
the hospital staff, clinicians and health workers are provided with information,
such as booklets or posters, to improve their knowledge about the disease and
to explain the rationale for conducting active surveillance. At the meeting, the
standard case definitions should be introduced, and it should be emphasized
that all cases that fit the case definition must be reported, even if the diagnosis
is uncertain. Clinicians must be assured that the results of laboratory investigations
will be sent to them as soon as they are available.

One staff member in each facility should be identified who will be the focal point
for that institution, responsible for assisting in active case detection and reporting.

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In addition to active case detection by staff, regular surveillance visits to the
reporting site should be conducted by the surveillance officer. The frequency of
visits to any particular site is determined by the likelihood of suspected cases
being admitted, so that timely epidemiological investigations can take place.
If the likelihood of a suspected case being seen at the institution is high, the
surveillance officer should make weekly visits ; if the likelihood is medium, the
visits can be monthly, and if the likelihood is low, the visits can be quarterly.
Annex 4 gives examples of active surveillance monitoring forms.

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The five key steps in an active surveillance visit are summarized below and
given in more detail in Annex 3.
1. Visit all places in a hospital where cases might be found. Cases might be
seen in both outpatient departments and inpatient wards. For instance, an
uncomplicated case of measles will be seen and treated in an outpatient
department, while a measles case with complications might be admitted to
the paediatric ward, and measles cases with neurological symptoms might
be admitted to a neurology ward.
2. Examine all records that might yield information. Outpatient registers, inpatient
registers, discharge summaries, laboratory request forms and hospital record
rooms can all yield useful information.
3. Consult anyone who might know of a case. It is always preferable first to contact
the focal point of the institution on every visit, who might already have a list of
cases or records. Then, meetings should be arranged with department heads,
chiefs of units in the department, resident doctors, staff nurses in charge of
indoor wards, laboratory chiefs and doctors in the emergency room.

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4. Collect the information on suspected cases on standard questionnaires according

to the disease.
5. Take appropriate action when a case is found. The staff nurse or doctor on
duty should be informed that a suspected case has been found, and the case
should be worked up on a standard questionnaire. Appropriate specimens
should be collected and sent to the designated laboratory, and arrangements
should be made for follow-up examinations and feedback of laboratory results
to the reporting hospital. Appropriate infection control measures should be
implemented in the health facility to prevent disease transmission.

Active surveillance visits should be monitored closely. One way to keep a record is
to note on the margins of the hospital or clinic registers the date of the visit, name
of the person examining the records and the number of cases that were detected
during the visit. Permission to write on the registers should be obtained from the
institutions’ authorities beforehand.

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There is wide variation in the level of detail required from surveillance data collected.
No matter what type of surveillance is chosen, the starting point is a standard case
definition.

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A standard case definition is an agreed set of criteria, usually clinical, used to
decide if a person has a particular disease. Use of standard definitions ensures
that every case is detected and reported in the same way, regardless of where
or when it occurred or who identified it. The commonest case definitions for
vaccine-preventable diseases are given in Annex 2. As soon as a case meets the
standard case definition it is labelled as a ‘suspected’ case. Once necessary steps
for confirmation of diagnosis have been undertaken, including appropriate laboratory
tests, and the diagnosis is confirmed, the case is labelled as a ‘confirmed’ case.

HncYgdb^XgZedgi^c\
Some case definitions in Annex 2 do not refer to a specific diagnosis but rather
to a syndrome or collection of symptoms and signs. This improves the likelihood
of finding the disease of interest, although other similar diseases might also be
detected.

Example : The syndrome of rash and fever can describe measles, rubella or dengue
haemorrhagic fever. Further case investigation and laboratory specimen testing are
necessary to confirm which cases are of interest and which are not.

As a mid-level manager, you should encourage health workers to report cases on

the basis of the clinical picture of the disease (signs and symptoms) and on the ba-
sis of their experience and clinical judgement. It is better to have a system that over-
reports suspected cases than one that fails to report communicable diseases in a
timely manner. Suspected cases can always be confirmed or discarded after further
investigation ; a missed case is a fault of the surveillance system, a discarded case
is not.

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8VhZhidWZ^ckZhi^\ViZY
The objectives of the disease control programme in your country must be
considered when deciding on the number of cases to be investigated ; however,
as a general rule :
1. If the disease is under eradication or elimination, every suspected case
should be investigated.
2. If the disease is to be controlled, it may not be necessary to investigate every
case, and it might be sufficient to investigate the index case(s) of a cluster to
confirm the diagnosis and to do an active search to determine the extent of
the cluster/outbreak.
3. Use case investigation forms to investigate cases. These are disease specific.
Information is usually collected face to face, sometimes requiring visits to the
home, hospital or community. The quality of data recorded on the form is
extremely important, as it will be used to decide whether public health action
is necessary.

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Monitoring is the systematic, continuous examination of data, measurement
of progress, identification of problems, formulation of solutions and planning
of interventions. It should be conducted regularly and, when necessary, lead
to corrective action. A range of strategies can be used to monitor the quality of
surveillance, some of which are summarized below. Details of monitoring an
immunization programme are given in Module 5.

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To get the most out of monitoring the quality of a surveillance system, including
the data that are reported, there must be a set of performance and quality
indicators against which progress and accomplishment can be measured. These
will vary by disease but can include the following :
s COMPLETENESS OF WEEKLY OR MONTHLY REPORTING INCLUDING @ZERO REPORTS 
s TIMELINESS OF WEEKLY OR MONTHLY REPORTING INCLUDING @ZERO REPORTS 
s INVESTIGATION OF CASES WITHIN  HOURS OF BEING REPORTED 
s PROPORTION OF CASES FOR WHICH SPECIMENS WERE COLLECTED AND SENT TO A
laboratory ;
s MAPPING OF REPORTING SITES TO ENSURE THAT ALL AREAS ARE COVERED

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A well-designed indicator is an independent measure that can be used in different

settings so that comparisons can be made. Module 5 of this series (Monitoring the
immunization system) provides more details on designing and using indicators.

Many documents have been published describing disease-specific indicators and

performance measures for both immunization coverage and disease control. The
box below shows the recommended indicators for bacterial meningitis taken from
the WHO-recommended standards for surveillance of selected vaccine-preventable
diseases.

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fjVa^in[dgWVXiZg^VabZc^c\^i^h
Performance indicators of surveillance quality
s 0ERCENTAGE OF ALL PROBABLE CASES FOR WHICH #3&BLOOD
was obtained for evaluation *90%
s 0ERCENTAGE OF PROBABLE CASES IN WHICH A BACTERIAL PATHOGEN
was identified from CSF or blood :
– Among CSF with 10 or more white blood cells/ml3 *15%
– Among CSF with 100 or more white blood cells/ml3 *40%
s 0ERCENTAGE OF #3& ISOLATES WHICH ARE Haemophilus influenzae *20%

Note
Although persons with bacterial meningitis have a wide range of CSF white blood
cell counts the proportion of probable bacterial meningitis cases with identifiable
bacterial causes increases with increasing CSF cell count. For the evaluation of
perfomance, immunization personnel may wish to determine the proportion of
potential bacterial meningitis cases in which bacterial causes have been identified
in one or both of the above categories. Result below the target levels suggest
that some cases of bacterial meningitis are not being identified from the probable
cases and that laboratory and clinical practices should be reviewed.
Source : WHO-recommended standards for surveillance of selected vaccine-preventable diseases (WHO/V&B/03.01).

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eda^d

- Rate of non-polio acute flaccid paralysis (AFP cases) *1/100 000 children under
15 per year
- Proportion of AFP cases with 2 adequate stools taken within 14 days of paralysis
onset *80%

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Care must be taken to avoid double-counting cases when reporting them to
a higher level. Double-counting is accidental inclusion of the same case more
than once. This is possible for cases that are reported immediately, for instance
when both active and passive reporting systems are operating for the same
disease. One way to avoid duplication is to make a list of cases and check for
identical entries e.g. names and addresses or case numbers.

Learning activity 8.1. Completing a case investigation form

You are the mid-level manager in Bundu Province and have just received the
following case investigation form from Sister Mari at Luaga Health Centre, in a
low-risk district for neonatal tetanus.

Task 1 : What is the case definition for neonatal tetanus (refer to Annex 2) ?

Task 2 : Does the case investigation form give enough information to determine
whether this is a case of neonatal tetanus ? If not, what other information is
needed ?

Task 3 : What advice could you give to Sister Mari about completing a neonatal
tetanus case investigation form in future ?

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Sample investigation form for death from suspected neonatal tetanus

Investigator’s name : Sister Mari Investigation date : 21/10/2007
Case identification and household location
Name of respondent : Mambeni Battula Relationship to baby : Mother
Address of respondent : House 5
Baby’s date of birth : 17/10/2007 Baby’s date of death :
Age at death in days : 4 days Sex of baby : Male : – Female :
How many pregnancies has the mother had (regardless of outcome, including this one) ?___
Mother’s immunization status
Does the mother have an immunization card ? Yes : No :
Immunization history by : Card – Memory – Both – Unknown
How many TT doses did the mother receive during the last pregnancy : 1
How many TT doses did the mother received before the last pregnancy (on any occasion) : 2
If by card, give dates : 1.__/__ /__ 2. __ /__ /__ 3. __/__/__ 4. __/__/__ 5. __/__/__
Mother’s antenatal care history
How many antenatal care visits were made during this last pregnancy ?
Delivery practices
Place of delivery ? Health facility : – Home : – Outside : – Other : – Unknown :
Who assisted with the delivery ? Doctor : – Midwife : – Nurse : – TBA : – Relative : – Nobody :
Other : – Unknown :
On what surface was the baby delivered ? (MVXÀSSV
What was used to cut the cord ? Kitchen knife
Was any substance put on the cord stump ? Yes : – No :
If yes, specify Unknown
Baby’s signs/symptoms - ask respondent to describe in open-ended questions and record the findings
below. Do not ask the questions literally.
Did the baby suckle normally for at least the first 2 days of life ? Yes : – No : – Unknown :
Did the baby stop sucking after the first 2 days ? Yes : – No : – Unknown :
Baby’s age at which illness was suspected by the mother/informant Days : 4 – Unknown :
Did the baby have the following signs :
Spasm when stimulated by touch, sound or light ? Yes : – No :
Developed “ pursed lips ” and/or clenched fists ? Yes : – No :
Become rigid or stiff as illness progressed ? Yes : – No :
Had tremors, fits or stiffness ? Yes : – No :
Ask the mother to describe the baby’s illness, and record the responses on the back of this form.
Treatment and outcome
Was the sick baby taken to a health facility ? Yes : – No : – Unknown :
If yes, give name of health facility : ___________________________________________________________
What was the final outcome for the baby ? Alive : – Dead : – Unknown :
Final diagnosis by the health facility___________________________________________________________
Visit the health facility if there is doubt whether the case died of neonatal tetanus.
Case response
Has the mother received TT since the birth of this baby ? Yes : – No : – Unknown :
Did other women in same locality receive TT in response to the case ? Yes : – No : – Unknown :
Conclusion
What does the respondent say was the cause of the baby’s death ? ________________
On the basis of the evidence, was this a case of neonatal tetanus ? :
Confirmed case : – Suspected case : – Discarded case : – Unable to classify :
Comments :

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Learning activity 8.2 : Diphtheria case investigation

You are the mid-level manager in Idzuvic Province. According to the disease control
guidelines of your country, the aim of the diphtheria surveillance programme is to
control the disease and prevent epidemics.

Two suspected cases of diphtheria have recently been identified by active

surveillance in a high-risk district in your province.

Task 1 : On the basis of the information in Annex 2, should you complete an

individual case investigation for each of these cases ?

Task 2 : If you decide to investigate, what information or specimens should be

collected ; who will gather the data and from where ?

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BZi]dYh
A case reported from the periphery meeting the standard case definition is
called a ‘suspected’ case. A suspected case has the signs and symptoms of the
disease and meets the standard case definition. Suspected cases need to be
investigated further. If a suspected case has an epidemiological link to another
confirmed case and/or has positive laboratory tests, it is ‘confirmed’. Laboratory
confirmed cases do not need to demonstrate an epidemiological link to a
confirmed case because laboratory confirmation alone is sufficient to confirm a
case.

The laboratory tests necessary to confirm cases of the other vaccine-preventable

diseases, the clinical pictures and case definitions are described in Annex 2.
Tetanus is the only vaccine-preventable disease for which the clinical case
definition is sufficient for confirmation, as laboratory confirmation and
epidemiological links are often not possible.

The diagnostic methods used to confirm a case of vaccine-preventable disease

are described below.

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To meet the standard case definition, cases must present with the signs and
symptoms listed in the nationally agreed standard case definition for that
disease. For example, the measles standard case definition might be : fever and
maculopapular rash and cough or coryza or conjunctivitis.

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An epidemiological association can be proven when a case can be linked back to
contact with a laboratory-confirmed case any time during the infectious period.
For example, an epidemiological association for measles might be as follows : 15
days ago, a child with measles confirmed by a blood test attended a party with
another child, who now has a rash. The incubation period of measles is 7–18 days
and rarely up to 21 days. The usual period between exposure and development of
rash is around 14 days.

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For laboratory confirmation, results must be available for specimen(s) that have
been collected, shipped and tested adequately, and indicate acute infection. For
example, a laboratory confirmation for measles might be the presence of measles-
specific immunoglobulin M (IgM) antibodies in the serum in a sample collected
4–28 days after the onset of rash.

Annex 2 describes the necessary laboratory tests for confirming cases. Specimens
of blood, cerebrospinal fluid, stools or nasopharyngeal secretions might be required,
depending on the disease. Guidelines are available for the collection and shipment of
specimens. Before collecting specimens, call or otherwise contact the laboratory to
find out the exact requirements, because the specimens might not be analysed if they
were incorrectly collected, handled or shipped, or if the accompanying documentation
is insufficient.

Are laboratory specimens needed for every case ?

For vaccine-preventable diseases subject to eradication or elimination, laboratory

specimens are needed from every suspected case. For example, stool samples
should be taken from all cases of acute flaccid paralysis and blood samples from
suspected measles cases in countries in the elimination phase.

For other vaccine-preventable diseases, including those subject to control, specimens

are not always needed from every case, and it may be sufficient to take a sample of
specimens (as per national policy) to confirm an outbreak. Note that no specimens are
required for neonatal tetanus, because a clinical diagnosis can confirm the disease.

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CdiZh/

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*$H[fehj_d]

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The number of cases of many vaccine-preventable diseases can be reported on
one form, a disease surveillance report. Aggregate data give a quick summary
of the magnitude of the problem, covering several diseases, but are not detailed
enough to enable case tracking. Aggregated data can be useful for analysis and
display when full details are not required and are often used for reporting monthly
data from passive surveillance systems.

A^cZa^hih
A line list is a convenient means for consolidating information on a number of
cases of the same disease ; it includes more detail than an aggregated report.
Data acquired from case investigation forms should be entered as soon as
possible into a line list, thereby allowing prompt analysis and visual assessment
and identification of possible clustering. An example of a line list for AFP cases
is given in Annex 4.

8VhZgZedgih
Case-based surveillance data provide details of individual cases of vaccine-
preventable diseases. Case-based surveillance requires the use of a standard
case definition and a case investigation form to record information, such as the
patient’s name, age, immunization status, date of last immunization against the
suspected disease, address, date of disease onset, suspected diagnosis and
laboratory results (when available). Case-based data are often used for diseases
that require urgent public health action or are subject to accelerated disease
control goals or during suspected outbreaks of epidemic-prone diseases, such
as diphtheria, meningitis and yellow fever. An example of a case investigation
form for neonatal tetanus is given in Learning activity 8.3.

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As indicated above, the disease control guidelines in each country give the control
objectives for each disease, and these objectives determine the frequency of
surveillance reporting and the types of report needed. Reports are usually sent
from the level where the disease was detected first (perhaps by a village health
worker or district health officer), through each administrative level to provincial
and national authorities. When immediate reporting is required, the priority is to
notify a higher level as soon as possible, although the report should be copied to
other levels, for information and to avoid duplication.

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This is the usual schedule for reports, and most data collected through
passive surveillance and sentinel sites are reported in this way. Monthly reports
comprise aggregated data (the total number of cases of each disease) rather
than providing details of each case, except for sentinel surveillance of some
diseases.

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Weekly reporting is usually used for diseases for which an active surveillance
system is in place or when the disease control objective is elimination or
eradication, such as for polio. These data are often sent in the form of a ‘line
listing’ or as case investigation reports.

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Immediate reporting is usually indicated if outbreaks of the disease are likely or
if the disease is subject to eradication or elimination initiatives. These diseases
are defined by national policy and can include measles, polio, maternal and neo-
natal tetanus and yellow fever. Immediate reporting can be done by e-mail, fax,
telephone, telegram, radio or any other rapid means available in the country.
The maximum possible essential information should be conveyed, including a
provisional diagnosis, location and age of the case. An immediate report should
be followed as soon as possible by a case investigation.

Learning activity 8.3 : Completing a line list

In Learning Activity 8.1 : Completing a case investigation form, you reviewed the
neonatal tetanus case investigation form submitted by Sister Mari. As mid-level
manager in Bundu Province, you are now required to send the weekly data on
neonatal tetanus to the national level.

Task 1 : Use the data on the case investigation form to complete this line listing.

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:mVbeaZd[a^cZa^hi^c\d[hjheZXiZYXVhZhd[cZdcViVaiZiVcjh
Country : Province : District :
Period covered by this line-list :
Mother’s Total TT Case- Case-
Location Place of Attendant at
EPID number Name Date of birth Date of onset Sex address or doses of investigation investigation Outcome Classification
delivery delivery delivery
village mother indicated ? done ?

1 2 3 4 5 6 7 8 9 10 11 12 13 14

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1. Unique case identification number (e.g. similar to acute flaccid paralysis EPID numbers)
2. The infant’s or parent’s name
3. Date of birth of infant
4. Date of onset of symptoms
5. Sex of the infant with neonatal tetanus
6. Address (at least village name) of the mother
7. Location (at least village name) where infant was delivered
8. Place of delivery, such as health facility, home or outside
9. Person attending the delivery : doctor, nurse, midwife, traditional birth attendant, neighbour, family member, nobody (mention only the person with the highest relevant qualification)
10. Total number of doses received by the mother before the birth of the infant, with year of last dose in brackets
11 Yes or No to indicate whether, on the basis of local guidelines, the case should be investigated further
12. Yes or No to indicate whether a case investigation was done ; if yes, a completed case investigation form should be available
13. Whether the infant is alive, dead or unknown vital status
14. Confirmed case of neonatal tetanus, discarded case, difficult to classify
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CdiZh/

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+$7dWboi_iWdZWYj_ed
In this section, we give examples of data analysis that the mid-level manager
can perform. Analysis is essential for understanding how well an immunization
programme is performing and for identifying gaps. Data analysis also provides
the basis for taking action, be it introducing new vaccines, targeting communities
at risk or modifying programme design.

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Data are often analysed with three questions in mind.

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Extract the date of onset of symptoms for all reported cases. The number of cases
occurring in a month or in a week is then calculated. This data is plotted with the
weeks or months on the X axis and the number of cases on the Y axis. Any clustering
of cases over the reporting periods (month or week) will immediately become visible.
In case of some short but explosive outbreaks (e.g. cholera, ebola etc.) the number
of cases by day may need to be plotted.

Seasonal variations in the incidence of some diseases (for example, influenza and
measles) are more noticeable than for other diseases (such as tuberculosis). When
immunization coverage increases, seasonal variations may become blurred.

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1800

1400

1200
Number of measles cases

1000

800

600

400

200

0
May

May

May

May

May
Mar

Mar

Mar

Mar

Mar
Nov

Nov

Nov

Nov

Nov
Sep

Sep

Sep

Sep

Sep
Jan

Jan

Jan

Jan

Jan

Jan
Jul

Jul

Jul

Jul

Jul

winter/ winter/ winter/ winter/ winter/

spring spring spring spring spring

1991 1992 1993 1994 1995

Year (in months)

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Some diseases naturally occur periodically as epidemic years followed by non-

epidemic years. Typically, an epidemic year will be followed by one or more years
with relatively few cases of the disease, until another epidemic year occurs.
Increasing immunization coverage changes the epidemic pattern so that the
time between epidemics increases.

When disease incidence reaches low levels due to effective immunization

activities, the epidemic pattern might not be evident. In analysing surveillance
data, consider the influence of epidemic patterns by asking yourself :
s (OW DOES THIS YEARS PATTERN COMPARE WITH THOSE OF PREVIOUS YEARS 
s #AN THE INCREASE OR THE DECREASE BE EXPLAINED  #ONSIDER INTERVENTIONS SUCH
as improvements in routine immunization coverage or mass immunization
campaigns as shown in Figure 8C.

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higViZ\^ZhWnnZVg#8djcignM!&.)%"'%%,

Measles Measles Measles

epidemic cycle control elimination
Pre-vaccination Maintain low incidence Interrupt circulation
of measles virus

Vaccination starts

Accumulation of Accumulation of
susceptibles susceptibles

Outbreak Outbreak Outbreak

Number of measles cases

0 Time (in years)

Analysis of disease data over a long period can show trends that are important
for monitoring programme performance, such as a decrease in measles. Trend
analysis by time can reveal patterns that can help in finding suitable control
measures or predicting the likely extent of disease in the future.

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The place where the case was residing at the time of onset of symptoms must
be determined for all reported cases. The location of cases is then plotted on
a map either manually or with the help of computerized mapping programmes.
Any spatial clustering of cases will immediately become visible.

It is important to determine whether a group of cases is clustered in place and

time. This is often best displayed by plotting the location of cases on a local map
and writing the date of onset next to each case. This information can be used to
guide interventions, such as immunization response.

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?Vc"9ZX#'%%*

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Minimal data on a case, describing the person affected by the disease
(for example age, sex, immunization status and location) can help to target
interventions appropriately.

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Age 0-5 6-11 1-4 5-9 10-14 15-34 35-64 65+ Total
Sex months months years years years years years years
Male 0 0 0 2 10 35 24 1 72
Female 0 0 0 1 6 26 13 0 46
Total 0 0 0 3 16 61 37 1 118

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From the above age and sex distribution, one can see : (a) males are more
affected than females in the ratio of 2 :3 ; (b) very few cases in the young and
the elderly, 98 of 118 (83%) cases are in the 15-64 age group with the greatest
proportion 61 of 118 (52%) occurring in young adults 15-34 years of age. This
distribution can be seen for example in communities who depend on contact
with the forest to gather food or other forest produce and are therefore exposed
to various insects (e.g. ticks) that live in the forest. Able-bodied young males are
the population most at risk.

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VcVanh^h

It is important to determine whether the increase in the number of reported

cases is due to an increase in disease incidence or to better reporting when a
surveillance system is implemented in a region with no previous surveillance.

If an unusual increase in the number of cases of a vaccine-preventable disease is

reported, action in the form of surveillance and immunization might be required.
The nature of the surveillance and immunization responses is often determined
by the disease and by national policies, many of which are listed in Annex 1.

The increase in cases might, however, be associated with problems in the

immunization coverage or system, such as the cold chain or vaccine supply,
which require a response. Module 5 : Monitoring the immunization system
describes ways of solving problems in immunization systems that require
urgent, medium- or long-term action.

Always look carefully for the underlying causes of reported increases in vaccine-
preventable diseases in order to propose an effective intervention to control and
prevent disease transmission.

The surveillance response may involve :

s SEARCHES FOR ADDITIONAL UNREPORTED CASES ACTIVE SEARCH 
s DETAILED INVESTIGATION OF CASES CASE INVESTIGATION FORM 
s CONlRMATION OF SUSPECTED CASES LABORATORY CONlRMATION 
s ANALYSIS OF DATA TO UNDERSTAND THE SITUATION IN TIME PLACE AND PERSON 
s REPORTING CONCLUSIONS AND RESULTS OF THE ANALYSIS TO APPROPRIATE LEVELS 
s TAKING SUITABLE PUBLIC HEALTH PRECAUTIONS TO MINIMIZE SPREAD OF THE DISEASE 
s TREATMENT OF CASES AND CONTACTS APPROPRIATELY

Action may depend on the quality and detail of data on time, place and person,
for example, whether full case investigations or only simple counts of cases are
available.

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The immunization response to an increase in the number of reported cases will vary
greatly, depending on the disease and current policies. Some diseases, such as polio,
require urgent, large-scale supplementary immunization, as recommended by global
policy laid down by the World Health Assembly. For others, such as measles and
neonatal tetanus, the magnitude of the immunization response depends on national
or local policy (see Annex 1 and other disease-specific guidelines).

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The term ‘outbreak’ is generally used when the number of cases observed is
greater than the number normally expected in a given geographical area during
a given period. The definition can, however, vary depending on the nature of the
disease and the disease control objectives.

When an increase in the number of cases is observed, you should determine

whether the increase can be termed an ‘outbreak’ or an expected trend, for
example by season. As an outbreak can trigger a previously determined set of
activities, outbreak investigation and response are described separately in Annex 6.

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Learning activity 8.4 : Data analysis and action

As mid-level manager in Activia Province, you regularly analyse data to monitor

the performance of your immunization programme. The graphs below show
measles immunization coverage and incidence in two of your districts :

100 100

90 90

80 80

70 70

% coverage
60 60
Incidence

50 50 Needia district
40 40

30 30

20 20

10 10

0 0
1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003
Measles incidence rate per 100000

% vaccines coverage by 1 year of age

100 100

90 90

80 80

70 70
% coverage

60 60
Incidence

50 50
Performia district
40 40

30 30

20 20

10 10

0 0
1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Task 1 : What can you conclude so far about these two districts ?

Task 2 : What questions might you ask the district data manager to help you
understand the graphs better ?

Task 3 : What further data analyses might be useful, and what data would be
needed to perform them ?

Task 4 : What recommendations would you make to the (1) district data manager,
(2) provincial surveillance officers, (3) Ministry of Health ?

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,$ <[[ZXWYa

+#&IdgZedgi^c\h^iZh
Feedback to reporting sites encourages their continued involvement and
commitment. Feedback can consist of urgent feedback for an outbreak or
individual cases ; specific feedback such as the laboratory results of each
case of acute flaccid paralysis in the Polio Eradication Programme ; or general
feedback.

The main reasons for providing feedback are to :

s FACILITATE THE USE OF DATA BY PROVIDING AN ANALYSIS IN GREATER DEPTH &OR EXAMPLE
if the peripheral level is not computerized, the central level might provide
computerized tables, graphs and maps.
s PLACE LOCAL DATA IN THE CONTEXT OF REGIONAL DATA TO ALLOW COMPARISON OF DISEASE
incidence and programme performance ; visualize the extent of outbreaks
(localized or more generalized) ; allow enhanced surveillance and preventive
measures in cases where disease is reported in the surrounding region but
has not been seen in that area ; and improve performance by showing national
progress towards public health goals and comparing performance between
regions ;
s INCREASE THE MOTIVATION OF DATA PROVIDERS BY ACKNOWLEDGING THEIR HARD WORK
and making them aware that their data are analysed and used ;
s IMPROVE THE ACCURACY AND PROMPTNESS OF REPORTS 
s VERIFY WITH THE PERIPHERAL LEVELS THAT THE DATA RECEIVED AT MORE CENTRAL LEVELS
are correct.

Methods of providing feedback are :

s PERIODIC MEETINGS AND DISCUSSIONS WITH PARTICIPATION OF MID LEVEL MANAGER
and staff at peripheral levels ;
s SUPERVISORY VISITS TO DISTRICT LEVEL AND HEALTH CENTRES 
s QUARTERLY NEWSLETTERS HIGHLIGHTING IMPORTANT ACHIEVEMENTS AND PROBLEMS 
s talking to health centre staff when they visit the office of the mid-level manager.

+#'Idi]ZXdbbjc^in
As a mid-level manager, you should encourage your staff to inform communities
about services, and always involve local politicians, religious leaders, school
directors and teachers, community group leaders and parents in planning and
implementing disease control activities, including immunization.

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Community cooperation during house-to-house active searches is essential, as

community members often can provide comprehensive, accurate information about
travel and movement between communities that can be invaluable for mapping the
spread of disease. Other ways of providing feedback to and involving the community
are outlined in Module 2 : Partnering with communities.

+#(8VaXjaVi^c\kVXX^cZZ[[ZXi^kZcZhh
It is often useful to be able to calculate vaccine effectiveness (also known as vaccine
efficacy). This calculation is a useful tool for measuring how well a particular vaccine is
working in the field. It is especially helpful for mid-level managers, as it may help them
to identify problems in the quality of the programme, such as inadequate storage of
vaccines.

Consider the example of Needia District in Learning activity 8.4, which appeared
to have uncontrolled outbreaks of measles disease despite high immunization
coverage. In your response, you should have identified the following possible
reasons for this :
s INCORRECT COVERAGE DATA
s INCORRECT DISEASE DATA
s INCORRECT DIAGNOSIS OF MEASLES THAT IS THIS WAS NOT AN OUTBREAK OF MEASLES
but of some other clinically similar disease).

But did you consider that the data were correct and there really is an uncontrolled
outbreak of measles disease despite high immunization coverage? It is possible. One
explanation might be that the measles vaccine was damaged due to poor storage,
possibly in the Needia District store before being distributed to each health facility.

Calculating the vaccine effectiveness could clarify whether the situation in Needia
District is due to a data problem, a diagnosis problem or a storage problem (in rare
circumstances, it might be due to all three). To calculate vaccine effectiveness, you
should use the following formula :

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Vaccine effectiveness = 1 – [PCV(1 - PPV)]

_____________
[(1 - PCV)PPV]

Where :
PCV is the proportion of cases vaccinated
PPV is the proportion of the population that is vaccinated (i.e. vaccine coverage).

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Warning : Mid-level managers must perform this calculation if they are concerned
about the effectiveness of a vaccine, rather than relying on a visual assessment
of the data, as visual assessment can be misleading.

For example : In Maxima Province, there is 95% measles immunization coverage

(PPV) and 60% of measles cases are vaccinated against the disease (PCV). This may
appear to be a high proportion, and possibly indicative of a vaccine effectiveness
problem, but,

vaccine effectiveness = 1 – ___________

[0.6(1 – 0.95)] = 1 –____
0.03 = 1 – 0.08 = 0.92.
[(1 – 0.6)0.95] 0.38

Therefore, the effectiveness of the measles vaccine in Maxima Province is 92%,

which is satisfactory, and it is incorrect to blame the vaccine. This situation often
occurs in areas where there is high immunization coverage.

Learning activity 8.5 : Calculating vaccine effectiveness

You are the mid-level manager in Batavia Province and are conducting a review
of the immunization programme quality in four districts. You have noticed that
Stevo District has a high proportion of measles cases in persons who have
been vaccinated against the disease, and you decide to investigate. As well as
reviewing other aspects of quality in each district, such as data, you decide to
calculate vaccine effectiveness.

Task 1 : First, without calculating anything, look at the graph below and see if
you can estimate which district has the highest vaccine effectiveness.

100

90

80

70

60
Percentage (%)

50

40

30

20

10

0
District Davo District Jono District Richo District Stevo
PPV 50 80 90 99
PCV 10 30 47 90

Immunization coverage % of cases with a history of immunization

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Task 2 : Now, using the formula in Figure 8E, calculate the vaccine effective-
ness in each of the four districts of Batavia province.

Task 3 : Was your initial assessment correct ? If not, explain why you may have
made a mistake. If your initial assessment was correct, describe how the vaccine
effectiveness differs in each district and suggest reasons why this might be.

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()

6ccZm&/7^Wa^d\gVe]n
1. Fifty-eighth World Health Assembly Resolution WHA58.3 : Revision of the
International Health Regulations.
2. Guidelines on the transport of infectious substances (WHO/CDS/CSR/
LYO/2005.22). Geneva, World Health Organization, 2005.
3. Immunization in practice : A practical guide for health staff. Geneva, World
Health Organization, 2004.
4. Making surveillance work. Module 1 : Rapid assessment of surveillance
for vaccine-preventable diseases (WHO/V&B/01.08). Geneva, World
Health Organization, 2001.
5. Making surveillance work. Module 4 : Data management (WHO/V&B/01.11).
Geneva, World Health Organization, 2001.
6. Measles/rubella : manual for the laboratory diagnosis of measles and ru-
bella virus infection (WHO/V&B/00.16). Geneva, World Health Organization,
2000.
7. Updated guidelines for evaluating public health surveillance systems.
Morbidity and Mortality Weekly Report, 2001, 50 :1–35.
8. Module on best practices for measles surveillance (WHO/V&B/01.43).
Geneva, World Health Organization, 2001.
9. Polio laboratory manual, 4th ed. (WHO/IVB/04.10). Geneva, World Health
Organization, 2004.
10. WHO-recommended standards for surveillance of selected vaccine-preventable
diseases (WHO/V&B/03.01). Geneva, World Health Organization, 2003.
11. Yellow fever : manual for the monitoring of yellow fever infection
(WHO/IVB/04.08). Geneva, World Health Organization, 2004.

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6ccZm'/HjgkZ^aaVcXZVcYgZhedchZVXi^k^i^Zh[dghZaZXiZYkVXX^cZ"egZkZciVWaZY^hZVhZh
Vaccine-Preventable Diseases Disease control objectives What symptoms should be Case definition Recommended type(s) of Investigation Confirmation of the case Data collection tools Surveillance and Use of data for decision-making
reported (syndromic reporting) surveillance immunization response
Polio Eradication of the virus. All cases of acute flaccid paralysis (AFP) should (1) Any child under 15 years of age with sudden Active : all hospitals, clinics, and other sites All AFP cases under 15 years of age or with Laboratory : Isolation of wild poliovirus in one or both 1.Case investigation form filled for each Surveillance : Visit reporting sites and look for - Track wild poliovirus circulation.
be reported. onset of floppy paralysis OR seeing children are visited regularly to find paralytic illness at any age where polio is the stool specimens. AFP case. AFP cases in the area, including active search in - Monitor performance of surveillance (by means of the standard
(2) any person of any age with paralytic illness if AFP cases. All reported or rumoured outbreaks suspected should be reported immediately and Clinical : Residual paralysis at 60 days, 2. Line list all AFP cases. Should include the the community. indicators) in all geographical areas and focus efforts in low-perfor-
polio is suspected. should be investigated immediately. investigated within 48 hours, and two stool OR death before follow-up, name, age, address, sex, immunization status, Immunization : Appropriate, large-scale, ming areas.
specimens should be collected at least 24 hours OR lost to follow-up. lab specimen collection dates and lab results, supplementary immunization activity in res- - Monitor seasonality to determine low season of poliovirus transmis-
apart within 14 days of the onset of paralysis. final classification and outcome. ponse to indigenous or imported wild poliovirus sion in the interest of planning national immunization days (NIDs).
confirmed case. All children under 5 years of age - Identify high-risk areas with a view to planning mop-up immunization
regardless of immunization status. campaigns.
- Provide evidence to certification commissions of the interruption of
wild poliovirus circulation.

Measles Depending on the national/regional measles All cases of fever with rash should be reported (1) Any person in whom a clinician suspects Control phase : Routine monthly reporting of Control phase : Outbreaks should be investi- Laboratory : Presence of measles-specific IgM antibodies Control phase : Aggregate data on number of Case management Control phase : Monitor incidence and coverage to assess progress
goal : and investigated. measles infection, OR aggregated data on clinical measles cases : by gated. During outbreaks it is useful to attempt in the serum (in absence of measles vaccination within cases by location, age groups and immunization Surveillance : Outbreak investigation, case and identify areas at risk. Describe the changing epidemiology of
1. Control phase : control of disease and (2) Any person with fever AND maculopapular location, age group and immunization status. to document measles mortality. Laboratory previous 6 weeks). Blood sample is collected within 28 status management, active search for measles cases in measles in terms of age, immunization status and interepidemic
prevention of deaths. Reduce the number of (non-vesicular) rash AND cough, coryza (runny Elimination phase : Active case-based confirmation may be attempted by sampling days after rash onset. Elimination phase : Case investigation form for the reporting sites. period. Assist in determination of optimal age groups to be targeted
measles deaths by 90% by 2010 (compared to nose) or conjunctivitis (red eyes). surveillance should be conducted and approximately 5 to10 cases per outbreak. Epidemiological : A case that meets the clinical case each suspect measles case. All cases entered Immunization : Appropriate strengthening by second opportunity for measles vaccination (including mass
2000 estimates). every case should be reported and investigated Elimination phase : Laboratory confirmation definition and is linked epidemiologically to a laboratory on a line list. of routine EPI and/or follow-up campaigns as vaccination campaigns).
2. Elimination phase : Achieve and maintain immediately. of every suspected case should be carried out. confirmed case. necessary. Elimination phase : Identify chains of transmission. Monitor the
interruption of indigenous measles transmission. Samples for measles virus detection should epidemiology (age groups at risk, interepidemic period, status of
Regional goals vary. be collected. measles) and accelerate immunization activities accordingly to avert
potential outbreaks.
During all phases : Detect and investigate outbreaks to ensure proper
case management, and determine why outbreaks occurred (e.g. failure
to vaccinate, vaccine failure or accumulation of susceptibles).

Neonatal Tetanus Elimination of disease as a public health All cases of neonatal deaths (deaths before a Any neonate with normal ability to suck and cry Active surveillance in selected hospitals, in High Risk areas : Investigate cases during and Clinical only, based on symptoms and signs as in the Aggregate reporting of : Surveillance : Search for unreported cases in Monitor progress towards maternal and neonatal tetanus elimination
problem (i.e. less than 1 NT case per 1000 live baby is 28 days old) should be reported. during the first 2 days of life combination with AFP and measles. as part of the immediate response. case definition. No laboratory confirmation. - Number of suspect NT cases and TT immuniza- area where case is investigated. in every geographical area (progress towards neonatal tetanus
births in every district). AND who, between 3 and 28 days of age, Low Risk areas : Investigate all suspect cases. tion status of mothers. Immunization : Immunize mother with TT, elimination is a proxy for maternal tetanus elimination)
cannot suck normally Case Investigation Form : To be used for all as well as all eligible women in surrounding - Identify high-risk geographical area and conduct supplemental
AND becomes stiff or has spasms (i.e. jerking cases coming from a low-risk area, and all cases neighbourhood or village(s) of the case. immunization activities.
of the muscles). still in hospital when the case is being reported. - Periodically verify the sensitivity of NT reporting by comparing
Line list : At district and superior levels. the number of reported cases with cases identified through active
Minimum data : Unique case-identifier, name surveillance, hospital record reviews, and active searches.
of mother, sex, address, DOB, date of onset,
outcome, classification, doses of TT received by
mother with dates.

Diphtheria Control of disease and prevention of epidemics. Severely ill children with sore throat. An illness characterized by laryngitis OR Routine monthly reporting of aggregated data. Investigate all suspect cases. Laboratory Clinical : see case definition. Aggregate data : on number of cases by Case management : Institute appropriate - Determine age-specific incidence rate, geographical area and season
pharyngitis OR tonsillitis Active surveillance in areas known to be at high specimens where feasible. Laboratory : Isolation of Corynebacterium diphtheriae location, age groups and immunization status anti-toxin and antibiotic treatment for cases of diphtheria cases to know risk groups and risk periods.
AND the presence of an adherent membrane of risk or outbreak situation. from a clinical specimen (the membrane), of infants. and contacts. - Detect and investigate outbreaks and implement control measures.
the tonsils, pharynx, and/ or nose. OR a fourfold or greater rise in serum antibody (but only if Case Investigation Form : To be used where Surveillance : Search for unreported cases in - Monitor incidence rate to assess impact of control efforts.
both serum samples are obtained before the administra- feasible. area from where case is reported.
tion of diphtheria toxoid or antitoxin). Line list (all cases) : Should include the name, Immunization : Immunize population of
age, address, sex, immunization status, lab susceptible age group in affected area with DTP,
specimen collection dates and lab results, final DT, Td as appropriate.
classification and outcome.

Pertussis Control of disease and prevention of deaths. Children with persistent fits of coughing A person with a cough lasting at least two Routine monthly reporting of aggregated data. Investigate all suspect cases. Laboratory Clinical : See case definition Aggregate data : on number of cases by Case management : Institute appropriate - Determine age-specific incidence rate, geographical area and season
especially if accompanied by a ‘whoop’ at the weeks Active surveillance in areas known to be at high specimens where feasible. Laboratory : Isolation of Bordetella pertussis from naso- location, age groups and immunization status antibiotic treatment for cases and contacts. of pertussis cases to know risk groups and risk periods.
end of each bout and vomiting. AND with at least one of the following symp- risk or outbreak situation. pharyngeal secretions OR positive paired serology. of infants. Surveillance : Search for unreported cases in - Detect and investigate outbreaks and implement control measures.
toms : (1) Paroxysms (i.e. fits) of coughing, (2) Case Investigation Form : To be used where area from where case is reported. - Monitor incidence rate to assess impact of control efforts.
Inspiratory whoop, or (3) post-tussive vomiting feasible. Immunization : Immunize population of
(i.e. vomiting immediately after coughing) Line list (all cases) : Should include the name, susceptible age group in affected area with
without other apparent cause. age, address, sex, immunization status, lab pertussis- containing vaccine.
specimen collection dates and lab results, final
classification and outcome.

Bacterial meningitis Control of disease and prevention of deaths. Any person with acute onset of fever (usually > Bacterial meningitis is characterized by acute 1. Routine monthly reporting of aggregated data. Investigate all cases, lumbar puncture with Laboratory : A child with a clinical syndrome consistent Aggregate data : on number of cases by Case management : Institute appropriate During the epidemic season :
Early detection of epidemics and implementing 38.5° C rectal or 38.0° C axilliary), neck stiffness. onset of fever (usually > 38.5° C rectal or 2. Epidemic season : routine weekly reporting CSF specimen sent to lab.(blood sample where with bacterial meningitis AND either 1) Culture of CSF location, age groups and immunization status antibiotic treatment for cases. 1. timely detection of epidemics.
an appropriate response. 38.0° C axilliary), and one of the following signs : of suspected and confirmed cases and active feasible). or blood, (2) Antigen detection of CSF or blood OR (3) of infants. Surveillance : Search for unreported cases in 2. provision of sufficient antibiotics for case management.
neck stiffness, altered consciousness or other surveillance. Epidemic season : lab confirmation of Gram stain of CSF. Case Investigation Form : To be used where area from where case is reported. 3. timely identification/confirmation of causal pathogen.
meningeal signs. Hib, meningococcal meningitis initial cases. feasible. Immunization (epidemic situation) : 4. selection and provision of appropriate vaccine for epidemic
and pneumococcal meningitis cannot be diffe- Line list (all cases) : Should include the name, Immunize population of susceptible age group response.
rentiated on clinical grounds alone. age, address, sex, immunization status, lab in affected area with appropriate meningitis
specimen collection dates and lab results, final vaccine. At any time, to describe the epidemiology of bacterial meningitis by
classification and outcome. Treat contacts. aetiological agent in order to :
1. determine the local disease burden (cases, deaths, disability).

Hepatitis B Control of disease and prevention of deaths as a Jaundice An acute illness typically including acute Routine monthly reporting of aggregated data. Normally not needed. Laboratory : Positive for IgM anti-HBc Aggregate data : on number of cases by Case management Monitor incidence rate to assess impact of control efforts.
result of chronic infection. jaundice, dark urine, anorexia, malaise, extreme Active surveillance in areas known to be at Blood samples where feasible. OR hepatitis B surface antigen (HBsAg). location, age groups and immunization status
fatigue and right upper quadrant tenderness. high risk or outbreak situation. of infants.
Note : Most infections occur during early child-
hood. A variable proportion of adult infections
are asymptomatic.

Yellow fever Control of disease and prevention of deaths. Jaundice and fever All cases characterized by acute onset of fever Routine monthly reporting of aggregated data Investigate all suspect cases. Laboratory Laboratory : Presence of yellow-fever-specific IgM or Aggregate data : on number of cases by Case management - Investigate suspect cases and collect laboratory specimens to confirm
Early detection of epidemics and implementing followed by jaundice within two weeks of the Active surveillance (case-based) in areas known specimens where feasible. a fourfold or greater rise in serum IgG levels (acute or location, age groups and immunization status Surveillance : Search for unreported cases in an outbreak and mobilize emergency immunization activities.
an appropriate response. onset of the first symptoms. to be at high risk or outbreak situation. Specimens should be collected to confirm convalescent) in the absence of recent yellow fever of infants. area from where case is reported. When case - Identify areas at risk of a yellow fever oubreak so that preventive
epidemics as rapidly as possible. Priority should vaccination, Case Investigation Form : To be used where is confirmed, outbreak investigation (including measures can be made before the outbreak occurs.
then be given to collecting specimens from new OR isolation of yellow fever virus, feasible. entomological investigation) to determine level
or neighbouring areas (other than the areas OR detection of yellow fever virus genomic sequences in Line list (all cases) : Should include the name, of transmission, and type of outbreak (sporadic
where epidemics are already confirmed). blood or organs by PCR. age, address, sex, immunization status, lab sylvatic case or urban outbreak).
Epidemiological : A suspected case that is epidemiolo- specimen collection dates and lab results, final Immunization : Appropriate, supplementary im-
gically linked to a laboratory-confirmed case or outbreak. classification and outcome. munization activity in the presence of continued
virus transmission.

Mumps Control of disease and prevention of deaths Swelling of the parotid or other salivary gland. Acute onset of unilateral or bilateral tender, Routine monthly reporting of aggregated data. Investigate all suspect cases. Laboratory Laboratory : Isolation of mumps virus from an appro- Aggregate data : on number of cases by Case management In countries where mumps is endemic, monitor the incidence and
self-limiting swelling of the parotid or other specimens where feasible. priate clinical specimen location, age groups and immunization status Surveillance : Search for unreported cases in coverage to assess progress and identify areas at high risk or with poor
salivary gland, lasting 2 or more days and OR at least fourfold rise in serum mumps IgG of infants. area from where case is reported. programme performance. Detect and investigate outbreaks.
without apparent cause. OR positive serology for mumps-specific IgM antibodies. Case Investigation Form : To be used where In countries with a high level of control, monitor the epidemiology
feasible. such as age groups at risk and the interepidemic period, and accelerate
Line list (all cases) : Should include the name, immunization activities according to potential outbreaks.
age, address, sex, immunization status, lab
specimen collection dates and lab results, final
classification and outcome.

Rubella and Congenital Rubella Syndrome (CRS) Prevention of congenital rubella syndrome (CRS) All cases of fever with rash Rubella : Fever maculopapular rash, cervical, Control phase : Routine monthly reporting of Control phase : Case investigation of suspected Laboratory : CRS : an infant with clinically-confirmed CRS Aggregate data : on number of cases by Control phase : outbreak investigation and Understanding epidemiology and burden of CRS and its epidemiology
suboccipital or postauricular adenopathy, or aggregated data on clinical CRS and rubella CRS cases 0-11 months ; Rubella outbreak who has a positive blood test for rubella-specific IgM. location, age groups and immunization status analysis. to guide rubella immunization strategies. Investigate rash illness in
arthralgia/arthritis. cases by location, age group and immunization investigation. Rubella : rubella-specific IgM. of infants. Elimination phase : Outbreak investigation pregnancy and follow up. Identify high-risk areas, age groups and
Suspected CRS : an infant 0-11 months if status. Elimination phase : Same as control plus : im- Case Investigation Form : To be used where plus search for and investigation of rash+fever populations for rubella immunization, linked with measles surveillance.
mother has a history of rubella during pregnancy. Elimination phase : Active case-based mediate case investigation of all rash and fever feasible. cases in pregnant women.
OR : an infant 0-11 months with heart disease, surveillance should be conducted and every cases, including collection of blood samples for Line list (all cases) : Should include the name, Immunization all phases : no immunization
and/or suspicion of deafness and/or one or more CRS case should be reported and investigated. laboratory confirmation. age, address, sex, immunization status, lab response indicated.
of the following eye signs : cataract, diminished Laboratory specimens should be collected from specimen collection dates and lab results, final
vision, nystagmus, squint, smaller eyeball every suspect rubella case. classification and outcome.
(microphalmus), or larger eyeball (congenital
glaucoma).

JE Control of disease and prevention of deaths Acute encephalitis syndrome (AES) Febrile illness of variable severity associated Areas where no JE transmission has been All clustered fever cases with AES should be Laboratory : Presence of JE- specific IgM in a single Aggregate data : on number of cases by Case management Understanding epidemiology and burden of JE.
with neurologic symptoms ranging from detected but where the vector is present : investigated and reported. sample of CSF or serum, as detected by a JE-specific IgM location, age groups and immunization status Surveillance : Search for unreported cases in Identify areas of JE transmission.
headache to meningitis or encephalitis. The Surveillance for AES syndrome ; investigation of capture antibody ELISA, where cross-reactions to other of infants. area from where case is reported. Identify the season of JE transmission.
encephalitis cannot be distinguished clinically clusters with fever. flaviviruses have been excluded, Case Investigation Form : To be used where Immunization : little role in an outbreak. Plan JE immunization campaigns before the high season.
from other central nervous system infections. Areas where disease is endemic with seasonal OR detection of JE virus, antigen or genome in tissue, feasible.
variation in transmission, and areas where epi- blood or other body fluid by immunochemistry or immu- Line list (all cases) : Should include the name,
demic JE is occurring : Routine monthly reporting nofluoroscence or PCR OR fourfold or greater rise in JE age, address, sex, immunization status, lab
of aggregated data. Active surveillance in areas virus-specific antibody in paired sera through IgG, ELISA, specimen collection dates and lab results, final
known to be at high risk or outbreak situation. haemagglutination-inhibition or virus neutralization test . classification and outcome.
(,

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1. Where: Make a list of likely places in a hospital where cases will be recorded.
s EMERGENCY OR CASUALTY DEPARTMENTS
s INTERNAL GENERAL MEDICINE PAEDIATRIC ORTHOPAEDIC WARDS
s OUTPATIENT CLINICS
s REHABILITATION CENTRES ESPECIALLY FOR ACUTE mACCID PARALYSIS

2. What : Identify which records should be consulted.

s INPATIENT RECORDS
s OUTPATIENT RECORDS
s ADMISSION REGISTERS
s DISCHARGE SUMMARIES
s DEATH RECORDS

3. Who : Decide who to consult.

s DOCTORS AND NURSES IN CHILDRENS WARDS
s OUTPATIENT STAFF

4. How : Decide how the information will be collected.

s FORM TO COLLECT DATA FROM RECORDS AND REPORTS
s CASE INVESTIGATION FORMS
s LIST OF STANDARD CASE DElNITIONS

5. When : Plan a response if a case is found

)F THE PATIENT IS STILL IN THE HOSPITAL 
s #ONDUCT A CASE INVESTIGATION AND COMPLETE THE FORM
s 4AKE A LABORATORY SPECIMEN IF RELEVANT
s .OTIFY THE CASE TO THE RELEVANT AUTHORITY ACCORDING TO NATIONAL POLICY
s %NTER THE DATA IN A LINE LIST

)F THE PATIENT IS NO LONGER IN THE HEALTH FACILITY 

s #OLLECT AS MUCH INFORMATION ON THE CASE AS POSSIBLE USING A CASE INVESTIGATION
FORM
s 3CHEDULE A VISIT TO THE CASE IF THIS IS FEASIBLE TO COMPLETE THE CASE INVESTIGATION
FORM
s #OLLECT A SPECIMEN FOR LABORATORY TESTING IF STILL RELEVANT
s $ECIDE WHETHER REPORTING CAN BE DONE IMMEDIATELY OR IF MORE INFORMATION IS
NEEDED

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 Aggregate Reporting of Vaccine-Preventable Diseases From Province Level-2005
Province___________________ Date Reported___________________
Total Number of Reporting Units in Province___________________ Number of Units Reporting this Month___________________

Aggregate Case Counts for Other VPDs

Aggregate Measles Reporting Adverse Events Following Immunizations (AEFI)
From All Reporting Sources
Routine Reporting Outbreak Reporting Measles/Rubella Lab
Year 2005
Month Number Number Number of Lab Neonatal Number of Number of Antigen
Number Number Number Number Diphthe- Encepha- Number of
of of Confirmed Cases Tetanus Pertussis Rubella Cases Hospita- (s)
of of of of ria litis Deaths
Measles Cases (NNT) of AEFI lizations Involved
Measles Measles Measles Samples
from from Measles Rubella
Deaths Outbreak Deaths Tested
routine Outbreak

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Column : 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

January

February

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March

April

May

June

July

August

September

October

November

December
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Total
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(-
 (.

State :___________________ Weekly Report Week No : ___________________

Report Date :_____/_____/_____ Line Listing of AFP Cases Beginning : _____/_____/_____
Reported by :________________________________ (Name) Ending : _____/_____/_____
Case ID State District Block Religion Sex Date Date Date Date Total Date Fever Asym. Hot Date Date Date Result Final
Number Code Name Name of of birth Paralysis Case Case Doses last at Paral. AFP Collection Collection F/up F/up Dx
(EPID Number) child Onset Notif. Invest. Invest. OPV Onset case Stool 1 Stool 2 Exam Exam
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16)

IND-

IND-

IND-

IND-

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IND-

IND-

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IND-

IND-

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IND-

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IND-

IND-

IND-

IND-

(1) Religion : H = Hindu / M = Muslim / O = Others (9) Fever at onset of paralysis : 1 = YES / 2 = NO / 9 = Unknown
(2) Sex of child : M = Male / F = Female (10) Asymmetric paralysis : 1 = YES / 2 = NO / 9 = Unknown
(3) Date of birth (11) Hot AFP case : 1 = YES / 2 = NO
(4) Date of Onset of paralysis (12) Date of first stool specimen collection from case
(5) Date of case notification (13) Date of second stool specimen collection from case
(6) Date of case investigation (14) Date of follow-up clinical examination
(7) Total doses OPV : 99 = Unknown (15) Results of follow-up : 1 = residual weakness / 2 = no residual weakness / 3 = lost to follow-up / 4 = died
(8) Date of last OPV dose (16) Final diagnosis : 1 = Guillain-Barre Syndrome / 2 = Transverse Myelitis / 3 = other / 9 = unknown
 )%

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bZVhaZhVcYcZdcViVaiZiVcjh

Week > 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Reporting
facility
>

Date
Acute flaccid
paralysis
Measles
Neonatal
tetanus
Date
Acute flaccid
paralysis
Measles
Neonatal
tetanus
Date
Acute flaccid
paralysis
Measles
Neonatal
tetanus

Instructions : Enter the date of the active surveillance visit and the number of
cases found. Write ’ 0 ’ (zero) if no cases were found.

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ÓVXX^YeVgVanh^h!bZVhaZhVcYcZdcViVaiZiVcjh

Week > 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Disease
>

Acute flaccid
paralysis
Measles

Neonatal
tetanus

Instructions : Consolidate the active surveillance data to show the number of

cases of each disease found each week.

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)&

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What are the new International Health Regulations (2005) ?

The aim of the new regulations is to “ prevent, protect against, control and
provide a public health response to the international spread of disease in ways
that are commensurate with and restricted to public health risks, and which
avoid unnecessary interference with international traffic and trade“.

The new regulations require that countries must notify WHO within 24 hours of :
s all events that may constitute a public health emergency of international concern
within their territory, and
s ANY HEALTH MEASURES IMPLEMENTED IN RESPONSE TO THESE EVENTS

Do the regulations mention any specific diseases of concern ?

The regulations specifically mention that every case of smallpox, wild polio, severe
acute respiratory syndrome and human influenza caused by a new subtype must
be notified. Yellow fever and a number of other diseases are of special interest, but
not every case has to be notified.

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 )'

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+#&>cigdYjXi^dc
An investigation of a reported outbreak of any disease presents an opportunity
to put into practice all the principles of surveillance described elsewhere in this
module, including detection, investigation, confirmation, reporting, analysis
and feedback. In addition, the mid-level manager may be responsible for taking
action to prevent the spread of the outbreak.

The term ‘outbreak’ is generally used when the number of cases observed is
greater than the number normally expected in a given geographical area during
a given period. The definition can, however, vary, depending on the nature of the
disease and the disease control objectives.

For example : In a country that is implementing a measles elimination

programme, even a single case of measles constitutes an outbreak and should
be responded to as such. That is, the number of cases observed (1) is greater
than the number expected (0).

An outbreak investigation should be triggered by a suspected outbreak. Do not

wait until the outbreak is confirmed, because that may be too late.

+#'HiZeh^cVcdjiWgZV`^ckZhi^\Vi^dc

HiZe&#K^h^ii]ZVgZVXdcXZgcZY#
Alert your superiors to the suspected outbreak immediately, and inform
them of any necessary resources you will need to investigate and control it.
Before leaving for the field, ensure that all logistical, technical and administrative
preparations have been made, including vehicles, fuel, funding, forms and travel
approvals.

HiZe'#KZg^[ni]ZY^V\cdh^hVcYXdcÒgbi]ZZm^hiZcXZd[VcdjiWgZV`#
Perform clinical examinations and undertake appropriate laboratory investigations
of suspected cases. Use a disease-specific case investigation form, and complete
one form per suspected case. The form should contain, as a minimum, the
identification data, age, sex, immunization status, address, history, details of
specimens taken and sent for laboratory investigation, results of investigation
(filled in when these are received), outcome (recovered, sequelae, death), and
final diagnosis. Details of disease-specific data collection tools and laboratory
specimens are given in Annex 2.

Use the preliminary data to define the case clearly.

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Sometimes the outbreak response is initiated after only one or two suspected
cases have been found, and there may be cases that have not been reported.
The search for and finding of unreported cases may determine what action
should be taken even before these cases have been confirmed. The search for
additional cases must include health facilities and the community.

s Health facilities : Visit the health facilities serving your catchment area. Talk to the
doctors and nurses to see if they are seeing suspected cases of the disease you
are investigating. Visit hospital wards and outpatient departments, and search
all patient registers for cases that fit the case definition or diagnoses consistent
with the disease under investigation.
s The community : Visit the communities from which cases were seen in the
health facilities. Talk to community leaders and others who might have influence
in the community. If feasible, organize a rapid house-to-house search of the
affected area(s) to find similar cases.

Alert all reporting sites in your catchment area and ask for daily reports of suspected
cases. Determine the extent of the outbreak by visiting or calling health facilities in
neighbouring areas. Depending on the disease, you might need to trace contacts.

HiZe)#9ZhXg^WZi]ZdjiWgZV`#
From the case investigation forms, create a line list with the name, age, address,
sex and immunization status of each case. Include laboratory results as soon as
these become available. Decide if sufficient laboratory results are available or
whether more specimens are required ; e.g. if a laboratory confirms the clinical
diagnosis of measles in a suspected measles outbreak, specimens need not be
collected from all cases ; however, if the laboratory results show that the cases
are due to rubella, more specimens might be needed to establish whether the
outbreak is purely of rubella or a mixed measles and rubella outbreak.

Analyse the data on the case investigation forms. Draw an epidemic curve and
a spot map. In addition, analyse the immunization status and ages of cases.
Develop hypotheses about the source and spread of the disease. A detailed
analysis will allow description of the chain of events leading to the outbreak and
the progress of control measures.

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8]Vgih]dl^c\i]ZcjbWZgd[bZVhaZhXVhZhgZedgiZYeZgbdci]
10
9
8
7 ( = one case)
6
5
4
3
2
1
0
Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec
Source : Immunization in practice : A practical guide for health staff. Geneva, World Health Organization, 2004.

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 ))

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It is usually possible to manage an outbreak by implementing a range of activities,
which include rapid identification of new cases, treatment or management of cases
and sometimes segregation or isolation to prevent additional spread. Specifically,
attention must be paid to :
s CASE MANAGEMENT EG ADMINISTRATION OF ANTIBIOTICS FOR DIPHTHERIA CASES AND
vitamin A for measles ; exclusion of pertussis cases from school) ;
s SURVEILLANCE AND CORRECTION OF PROBLEMS IN THE SURVEILLANCE SYSTEM EG ACTIVE
surveillance to find more cases ; review of completeness of zero reporting and
timeliness of reporting) ;
s IDENTIlCATION OF OTHER PROBLEMS IN THE IMMUNIZATION SYSTEM EG EVALUATION
of components such as coverage, status of cold chain, training and availability
of manpower at various levels).

Some outbreaks can be contained or halted by a rapid, focused, immunization

response. The decision to respond to an outbreak by launching immunization is
determined by national policy, usually based on international recommendations such
as those listed in Annex 2 and the WHO-recommended standards for surveillance of
selected vaccine-preventable diseases.

The following issues should be considered in preparing an immunization response

to an outbreak :
s EXTENT OF THE OUTBREAK INCLUDING GEOGRAPHICAL CONSIDERATIONS 
s starting date of the immunization campaign and the time available for completion;
s AVAILABILITY OF ADEQUATE RESOURCES TRANSPORT SUPPLIES PERSONNEL AND FUNDS 
s A GOOD LOGISTICS PLAN DETAILS OF THE TARGET POPULATION VACCINE SUPPLY AND
clear delineation of responsibility.

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One of the most important parts of an outbreak investigation is ensuring that the
lessons learnt are communicated and acted upon. These lessons might refer to :
s SURVEILLANCE QUALITY EG IMPLEMENT ZERO REPORTING IN EVERY HEALTH CENTRE 
s performance of the immunization system (e.g. district immunization staff require
training in stock management and storage) ;
s PREPAREDNESS FOR AN OUTBREAK EG GUIDELINES FOR OUTBREAK INVESTIGATION AND
response needed) ;
s management of the outbreak, including investigation, response, problems
with the immunization system (e.g. consider developing guidelines for an
immunization response to measles outbreaks ; implement a packaging policy ;
evaluate refrigeration requirements).

The report should include details of the outbreak, the investigation, the response
to date, problems identified in the immunization system that are related to the
outbreak, and recommendations to prevent further outbreaks.

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Learning activity 8.6 : Strengthening the surveillance system

You are the immunization manager in a province with a population of 2 000 000.
Every year, a few cases of diphtheria are reported during the winter (first quarter
of the year). This year, you notice that the number of reported cases in the first
two months has risen to a total of 60 cases and six deaths, which is beyond
what was expected.

Details of 60 cases of diphtheria in first quarter of the year

Age (years) No. of cases % of all cases No. of deaths
0-4 3 5 0
5-9 9 15 2
10 - 14 15 25 1
15 - 40 33 55 3
Total 60 100 6

Task 1 : What additional data do you need ?

Task 2 : What analysis should you conduct ?
Task 3 : What are the possible reasons for the outbreak ?
Task 4 : What action should you take ?

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Revision exercise

You are the mid-level manager in Niallo Province and have been asked to help improve
the existing vaccine-preventable disease surveillance system, which is functioning
poorly. The system relies on government health workers sending reports ; however,
they are rarely completed and often arrive late. You have heard that there are
outbreaks of disease but have never received an official report.

Task 1 : For each of the seven steps outlined in this module, recommend and describe
one strategy that will help improve vaccine-preventable disease surveillance quality
in your province.
For each of the seven steps, recommend and describe one strategy
that will help improve surveillance quality.
1 Detection

2 Case investigation

3 Confirmation of the
diagnosis

4 Reporting

5 Analysis and action

6 Feedback and monitoring

quality

7 Outbreak investigation

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The World Health Organization has provided The Quality, Safety and Standards team
technical support to its Member States in focuses on supporting the use of vaccines,
the field of vaccine-preventable diseases other biological products and
since 1975. The office carrying out this immunization-related equipment that meet
function at WHO headquarters is the current international norms and standards of
Department of Immunization, Vaccines quality and safety. Activities cover: i) setting
and Biologicals (IVB). norms and standards and establishing
reference preparation materials; ii) ensuring
IVB's mission is the achievement of a world the use of quality vaccines and immunization
in which all people at risk are protected equipment through prequalification activities
against vaccine-preventable diseases. The and strengthening national regulatory
Department covers a range of activities authorities; and iii) monitoring, assessing and
including research and development, responding to immunization safety issues of
standard-setting, vaccine regulation and global concern.
quality, vaccine supply and immunization
financing, and immunization system The Expanded Programme on Immunization
strengthening. focuses on maximizing access to high quality
immunization services, accelerating disease
These activities are carried out by three control and linking to other health
technical units: the Initiative for Vaccine interventions that can be delivered during
Research; the Quality, Safety and Standards immunization contacts. Activities cover:
team; and the Expanded Programme on i) immunization systems strengthening,
Immunization. including expansion of immunization services
The Initiative for Vaccine Research guides, beyond the infant age group; ii) accelerated
facilitates and provides a vision for worldwide control of measles and maternal and
vaccine and immunization technology neonatal tetanus; iii) introduction of new and
research and development efforts. It focuses underutilized vaccines; iv) vaccine supply and
on current and emerging diseases of global immunization financing; and v) disease
public health importance, including surveillance and immunization coverage
pandemic influenza. Its main activities cover: monitoring for tracking global progress.
i) research and development of key
The Director's Office directs the work of
candidate vaccines; ii) implementation
research to promote evidence-based these units through oversight of
decision-making on the early introduction of immunization programme policy, planning,
new vaccines; and iii) promotion of the coordination and management. It also
development, evaluation and future mobilizes resources and carries out
availability of HIV, tuberculosis and malaria communication, advocacy and media-related
vaccines. work.

World Health Organization

20, Avenue Appia
CH-1211 Geneva 27
Switzerland
E-mail: [email protected]
Web site: http://www.who.int/immunization/en/