Epidemiologic Surveillance

Dambi Dollo University

Definition of Surveillance
o Surveillance is derived from the French ‘Sur’ (over)
and ‘veiller’ (to watch) - hence ‘to watch over’.
 Public Health Surveillance is an on-going
 systematic collection,
 analysis,
 interpretation and
 Dissemination of health-related data essential to the
planning, implementation, and evaluation of public
health practice.

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 Cont…
 Surveillance can be conducted globally, regionally
(like East Africa), nationally, or institutionally (single
health facility-focused).
 It is a mechanism that public health agencies use to
monitor the health of the community.
 It is for evidence-based setting priorities, planning
programs, and taking action to promote and protect
the public’s health.

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Basic Principle
 Public health surveillance’s main function is to serve
as an “early warning system” – providing timely
information needed for action
 (rapid reporting, confirmation, decision making and
response)

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Surveillance System’s Good Attributes
 Simple
 Flexible
 Acceptable
 Sensitive; able to detect the problem
 Good predictive value positive; good yield
 Representative
 Timely
 Cost effective
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Uses of Public Health Surveillance
 To estimate magnitude of the problem
 Early recognition of epidemics - detect sudden changes in
disease occurrence.
 To identify changes in agents, host factors and health practices
 To follow secular (long-term) trends
 Projections of future trends
 To evaluate public health programs
 To generate hypotheses and stimulate research

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Surveillance is
Information for Action

Public Health Action

Surveillanc Assess PH status
eCollection Detect outbreaks/epidemics
Analysis Monitor trends in endemic
Interpretation diseases
Dissemination Define PH priorities
Guide research
Monitor and evaluate
programs/interventions
Predict outbreaks/epidemics
7 Estimate future disease
07/08/2024impact
Sources of Surveillance Data
 Census data  Adverse drug reaction reports
 Mortality reports (along with  Special surveys (research data,
birth and death certificates) serologic surveys)
 Morbidity reports  Police records (injury, alcohol-
 Hospital data related)
  Information on animal
Absenteeism records (school,
workplace) reservoirs and vectors
  Environmental data (water,
Epidemic reports
 Laboratory reports and records food testing)
 Special surveillance data
 Drug utilization records
(injury, occupational H.)
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Selection Criteria for Disease Surveillance
 Magnitude of the disease

 Feasibility of control measures

 Need for monitoring and evaluating the

performance of a control program

 Resource availability

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 Types of Surveillance
There are 3 main types of surveillance:
1. Passive Surveillance: A surveillance where reports
are awaited and no attempts are made to seek reports
actively from the participants in the system.

2. Active Surveillance: A surveillance where public

health officers seek reports from participants in the
surveillance system on a regular basis, rather than
waiting for the reports.
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07/08/2024
 Types (Cont…)
3. Sentinel Surveillance: uses a pre-arranged sample of
reporting sources to report all cases of one or more
conditions.
 Usually the sample sources are selected to be those most
likely to see cases.
 Sentinel surveillance provides a practical alternative to
population-based surveillance.

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Main Purposes of Sentinel Surveillance
 To detect changes
 To direct and focus control efforts
 To develop intervention strategies
 To promote further investigations
 Provide the basis for evaluating preventive strategies and
activities

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 Types (Cont…)
Modified forms of surveillance include:

1. Intensified Surveillance: The upgrading from a passive

to an active surveillance system for a specified reason and
for a limited period (could be because of an outbreak).

2. Enhanced Surveillance: The collection of additional data

about cases reported under routine surveillance

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Critical Information in Surveillance
 Generally, a surveillance system should determine the Who,
What, When, Where, and How questions. The critical
information should include:
 Person: Age, sex
 Time: onset of disease, reporting period
 Place: Woreda, region
 Risk factors
 Number of cases (magnitude)
 Treatment outcome: deaths, recovery (seriousness)
 Mode of treatment: inpatient/outpatient
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Case Definition
 Case definition includes:
 Criteria: Signs and symptoms with or without a
laboratory test
 Restriction by time, place and person can be done
depending on the nature of the disease
 There are 3 classification of case definitions:
confirmed, probable, and possible cases.

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 Case Definition (Cont…)
Classification of case definitions:
1. Confirmed: a case definition by appropriate
laboratory test.
2. Probable: a case with typical clinical features of the
disease without laboratory confirmation
3. Possible/Suspect: a case with few of the typical
clinical features.
Use case definition consistently!!

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Case Definition: Example
Possible/
Confirmed Probable
Suspected
Malaria Case Malaria Case
Malaria
Presence of fever,
chills, headache, Presence of fever
arthralgia, back and headache of
Confirmed by pain…etc of sudden onset
laboratory test. sudden onset, but without
without laboratory
laboratory confirmation.
confirmation.

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Major Advantages of Case Definition
Facilitates early detection and prompt
management of cases.
Useful in areas where there is no laboratory.
Facilitates observation of trends.
Facilitates comparison more accurately from area
to area.

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Surveillance System With Laboratory Tests
Clear procedures need to be designed and
established for effective surveillance
system that address:
 Specimen and Data collection
 Transfer of Specimen and data
 Feedback

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Quality of Public Health Surveillance System
The major indicators of quality public health surveillance
system include:

I. Acceptability

II. Representativeness

III. Reporting completeness

IV. Reporting timeliness

V. Sensitivity of surveillance

VI. Specificity of surveillance

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I. Acceptability

 Willingness of persons conducting surveillance

and those providing data to generate accurate,
consistent and timely data.

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II. Representativeness

 The degree to which inference can be drawn

from the information gathered by the
surveillance system to the target population.

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III. Reporting Completeness

 Proportion of all expected reports in a

reporting system that were actually received.

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IV. Reporting Timeliness

 Proportion of all expected reports in a

reporting system received by a given date (due
date).

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V. Sensitivity of Surveillance
 The ability of a surveillance or reporting system to
detect true health events:

total number of health events detected by the system

total number of true health events

(as determined by an independent and more) complete

means of ascertainment

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VI. Specificity of Surveillance
A measure of how infrequently a system
detects false positive health events:

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Analysis of Surveillance Data
 Descriptive analysis: distribution by time, place and
person
 Frequency of events
 Calculate rates- need proper denominator
 Observe trends: comparison current data with expected
value, identify differences, and assess the relevance of the
difference
 Draw graphs to show long term (secular) trends

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 Analysis Cont…

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Dissemination of Surveillance Data
 Disseminate surveillance data to all stakeholders
 Those who provide the reports (health providers)
 The community – affected/potentially affected
 Decision makers
 Disseminate report locally, nationally or globally; as
deemed necessary
 Disseminate report timely and regularly
 Disseminate through appropriate media: newsletter or
bulletin (paper or electronic)
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 WHO

Federal MOH
 Central Referral
Supervision and feedback
Hospitals

Regional Health Bureau

 Regional hospitals
Data Collection, Analysis,  Regional laboratories
Action and Reporting
Zonal Health Department
 District Hospital
 PHC facilities

Woreda Health Office

 District hospital
 PHC facilities

The
community
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.
Reporting and Feedback Levels
(Local to International)
 Surveillance systems are networks of people and
activities that maintain the process and may function
at a range of levels, from local to international.

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Evaluating and Improving Surveillance
Systems
Should be evaluated periodically to forward
recommendations for improvement:
1. To identify elements of surveillance that should be
enhanced to improve its attributes,
2. To assesses how surveillance findings affect control
efforts, and
3. To improve the quality of data and interpretations
provided by surveillance.

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Common Limitations of Surveillance Systems
 Under reporting
 Lack of representativeness of reported cases
 Lack of timeliness
 Inconsistency of case-definitions
 Lack and shortage of qualified staff
 Lack of motivation

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Surveillance Vs survey
Surveillance Survey
 Relatively cheap - can often  More in-depth data could be
use existing systems and collected
health personnel  More accurate assessment of
 Allows monitoring of true prevalence
trends of disease over time  Can identify those which do
 Ongoing collection not warrant medical care
produces enough cases for But…
the study  Costly
But…  Represents only a single point
 Quality control may be the in time- does not show
major problem changes over time
 May not provide  Recall bias can be introduced
representative data (retrospective data)
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 Public Health Surveillance in
Ethiopia

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Background of Disease Surveillance in
Ethiopia
 Before 1998 → Multiple D/s Surveillances

 From 1998 – 2009 → Integrated Disease Surveillance and

Response (IDSR)

 Starting from early 2009 → Public Health Emergency

Management (PHEM)

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Public Health Emergency Management (PHEM)
 PHEM is the process of
 anticipating,
 preventing,
 preparing for,
 detecting,
 responding to,
 controlling and
 recovering from consequences of public health threats
so that health and economic impacts are minimized.
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IDSR and PHEM
 IDSR and PHEM employ simplified tools for data
collection and analysis & common channels for reporting
and feedback.
 IDSR & PHEM strengthened the capacity to detect and
respond to communicable disease threats and
emergencies.
 The integration helped to maximize effective utilization of
scarce resources.
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List of Priority Diseases for Surveillance in
Ethiopia
 Nationally, 23 disease were monitored until early
2009.
• From early 2009, twenty (20 but currently 22 )
diseases and conditions are identified as priority
diseases on surveillance which are immediately and
weekly reportable.

 Other diseases are included in HMIS

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Immediately Reportable Diseases
1. Acute Flaccid Paralysis (AFP)
9. /Polio
Rabies
2. Anthrax 10. Smallpox

3. Avian Human Influenza (H1N

11.1) SARS (Severe Acute Respiratory

4. Cholera Syndrome)

5. 12.
Dracunculiasis / Guinea worm VHF (Viral Hemorrhagic Fever)

6. Measles 13. Yellow fever

7. NNT (Neonatal Tetanus)

8. Pandemic Influenza A
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Weekly Reportable Diseases

Immediately Reportable Diseases Plus

14. Dysentery
15. Malaria
16. Meningococcal Meningitis
17. Relapsing fever
18. Malnutrition
19. Typhoid fever

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20. Typhus + all IRD 07/08/2024
Exercise/Assignment
 According to current PHEM concerns, determine whether IRD
or WRD ????????
1. MDSR

2. AEFI

3. MERS (Middle East Respiratory

4. GBS (Gullian Bare Syndrome) and

5. Microcephally of ZickaVirus
 What about these??????????????????
 Flooding, Earth quake, Volcanic Eruption, landslide
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Outbreak Investigation &
Control
Dambi Dollo University
Learning objectives
After the end of this session, students will be able to:
o State different level of disease occurrences
o List the rationale to investigate outbreak occurrence
o Discuss steps in the investigation of an outbreak
occurrence
o Describe types of outbreak occurrence
o Discuss the outbreak controlling strategies

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Epidemiology in Action
 Outbreak Investigations

 Public Health Surveillance

 Community Screening Programs

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Levels of Disease Occurrence
 Diseases occur in a community at different levels at a
particular time in time:
1. Expected Level (Predictable) and
2. Excess of expected

 Expected level of occurrence of disease

 Endemic: the usual presence of disease from low to moderate
level
==Malaria is endemic in the lowland areas of Ethiopia.
 Hypo/Meso/Hyper-endemic: a persistently lower or
moderate or high level of disease.
 Sporadic: Normally does not occur, but occasional cases
occur at irregular intervals
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Excess of what is expected
 Epidemic: The occurrence of health related condition/disease
in excess of the usual frequency

 Outbreak: Epidemics of shorter duration covering a more

limited area.

 Pandemic: An epidemic involving several countries or

continents affecting a large number of people.

example : HIV/AIDS,Covid-19 are pandemic.

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Levels of Disease Occurrence
.
(Endemic Vs Epidemic)
Number of Cases of a Disease

Epidemic

Hyperendemic

Endemic
Time

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Levels of Disease
.
Increasing amount of disease

Pandemic

Epidemic

Endemic

Sporadic

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What does outbreak investigation & control?
 It is the process of identifying:
o The cause of the epidemic
o The source of the epidemic
o The mode of transmission and
o Taking preventive and control measures

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Source of an outbreak information

 Routine surveillance

 Health professionals

 Affected community members

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What are the objectives for outbreak investigation?

1) To initiate control & prevention measures

 The most important public health reasons for
investigating an outbreak are to help guide disease
prevention and control strategies.
 These disease control efforts depend on several
factors, Including
 knowledge of the agent,
 The natural course of the outbreak,
 The usual transmission mechanism of the disease, and
 Available control measures

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2) Research and training opportunity
o Each outbreak should be viewed as an experiment
waiting to be analyzed
o It presents a unique opportunity to study the natural
history of the disease
o It could be a good opportunity to gain additional
knowledge on
 The impact of prevention and control measures
 The usefulness of new epidemiology and laboratory
techniques

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3) Public, political and legal obligations
o Politicians and leaders are usually concerned with control
of the epidemic
o Politicians and leaders may sometimes override scientific
concerns
o The public are more concerned in cluster of disease and
potentials of getting medication
o It is right of the community to get treatment/service and it is
government and our duty to protect the community
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4) Program considerations
o Occurrence of an outbreak notifies the presence of a
program weakness
o This could help program directors to change or
strengthen the program’s effort in the future to prevent
potential episodes of outbreak occurrence

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Steps of outbreak investigation and control
1. Prepare to field work
2. Establish the existence of outbreak
3. Verifying the diagnosis
4. Case definition and case finding
5. Perform descriptive epidemiology
6. Formulate hypotheses
7. Testing hypotheses
8. Refine hypothesis and additional studies
9. Implementing prevention and control activities
10. Communicate findings
 In practice, however, several steps may be done at the same time, or
 The circumstances of the outbreak may dictate that a different order
be followed
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Step 1: Prepare for field work
 Before leaving for the field, an investigator must be well
prepared to under take the investigation:

 Investigation (Knowledge in epidemiology and the disease of

concern is important)

 Administrative (Logistics, administrative procedures, travel

arrangements)

 Consultation (Health workers should know their role, and should

participate in the planning phase)

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Step 2: Establish the existence of outbreak
 An outbreak is the occurrence of more cases of disease than
expected level
 The investigator has to compare previous case load with the
current to assure the existence of the outbreak
 But be careful, excess cases may not always indicate
an outbreak occurrence rather it may be because:
 Change in population size
 Change in case definition
 Change in reporting procedure

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Step 3: Verifying the diagnosis
 The initial report may be spurious and arise from
misinterpretation of the clinical features
 Review clinical and laboratory findings to establish
diagnosis
 Goals in verifying the diagnosis includes:
 To ensure that the problem has been properly diagnosed
 To rule out laboratory error as a basis for the increase in
diagnosed cases
 To ensure the diagnosed disease is possibly epidemic

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Step 4: Case definition and case finding
 Prepare “case definition” before starting identification of cases
 It’s aim is to count all cases of the illness
 It is clinical criteria restricted by time, place and person
 Use sensitive or "loose case definition” early in the investigation and
use "tight or strict case definition” for testing hypothesis
= We can find additional cases in
- health facilities
- home visit in epidemic area( kebele or gote level )
=Information required include personal Identifier(name, tell, address),
demographic(age, sex, occupation), exposure history, clinical information(date of
onset, outcome, sign and symptom),who report? Information
= we will do line listing by taking the above information

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Classification of Case Definition
 Possible: cases with subjective signs and symptoms
consistent with the case definition.

 Probable: cases with objective signs and symptoms

consistent with the case definition.

 Definite: laboratory confirmed case

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Step 5: Performing Descriptive Epidemiology
 Once data is collected, it should be analyzed by time,
place and person
 The tools to be used when characterizing the epidemic
are epidemic curve, spot map and attack rate
 The characterization often provides clues about
etiology, source and modes of transmission that can be
turned into testable epidemiologic hypothesis

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1. Analysis of epidemic by time
 We use epidemic curve to analyze by time taking
- The X- axis; indicating time of onset
-The y-axis; indicating the number of cases appearing
 Epidemic curve can tell as
- nature of epidemic
- hint to etiologies – etiologic agent
- hint about source of exposure
 There are three principal types of epidemic
1. Common source – based on source of exposure
2. Propagative - touches mode of transmission
3. Mixed epidemic – share characteristics of both type
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1. Common source epidemic
 It occurs as a result of the exposure of a group of population to
a common source (etiological agent)
o It can result from a single source/ exposure of the
population to the agent
E.g: contaminated water supply, or food in a certain
restaurant
 Three types
1. Point common source
2. Continuous common source
3. Intermittent common source
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A) Point common source epidemic
 Single/ones/limited time exposure to the source
 All exposed hosts will develop disease within one
incubation period
 The epidemic usually decline after a few generations,
either because the number of susceptible hosts fall
below some critical level, or because intervention
measures become effective
 A rapid rise and gradual fall of an epidemic curve
suggests a point source epidemic

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 Typical Point source epidemics
Peak of Outbreak

Minimum
incubation
period

A single sharp peak of sudden onset

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B) Continuous common source epidemic
 If exposure to a common source continues over time for days,
weeks
 The epidemic curve has a plateau (multimodal epi curve)/ long
peak
 Range of exposures and range of incubation periods is different

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C) Intermittent common source epidemic
 Results in an irregular pattern of the epidemic curve that
reflects the intermittent nature of the exposure
E.g. waterborne outbreak
 Often the graph is atypical

Several sharp peaks

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2. Propagative /progressive epidemic
 It occurs as a result of transmission of an infectious agent from
one person to another directly or indirectly

 There is a successive generations of cases

 The epidemic curve in a progressive epidemic is usually

presence of successive several peaks, a prolonged duration,
and usually a sharp fall

 Can show geographic spread of the case

 Example; Malaria outbreak and different vector born disease

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Typical Propagated Epidemic Curve

No sharp peak
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3. Mixed Epidemic
 It shows the features of both types of epidemics
 It begins with a common source of infectious agent
with subsequent propagated spread because of person
– to- person transmission of the etiologic agent
 E.g. Majority of food borne outbreaks

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2. Analysis of epidemic by place
 A spot map is a simple and useful technique for
illustrating where cases live, work or may have been
exposed
 Area map if large area is affected
 It is important to indicate source of outbreak

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3. Analysis of epidemic by person
 Characterizing an outbreak occurrence by person is how we
determine what populations are at risk for the disease
 Host characteristics: age, race, sex, or medical status and
exposures-occupation, leisure activities, use of medications,
tobacco and drug use etc…
 These influence susceptibility to disease and opportunities for
exposure to risk factors

 We use attack rates to identify high risk groups

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Step 6: Formulating hypothesis
 Depending on the outbreak, the hypothesis may address
 The exposures that caused the disease
 The mode of transmission
 Using :
 Subject-matter knowledge
 Descriptive epidemiology
 Talking with patients
 Talking with local officials
 The hypotheses should be testable

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Step 7: Testing the hypothesis
 Here doing analytic studies may be useful.
 Association between the postulated exposure factor and the
disease is tested using analytic design
1. Case control 2. Retrospective Cohort
 Appropriate measure of association should be made
 for case control, odds ratio
 for cohort design, relative risk
 Significance of statistics should be done,
 (Chi-square is the appropriate test, and P-value is estimated at
5 %.)
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Step 8: Refining hypotheses and additional studies
o Search for additional cases: Locate unrecognised or
unreported cases
o Environmental studies are equally important in some
settings

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 Step 9: Implementing control and prevention
In outbreak investigation, the primary goal is to control and
prevent the outbreak.
Implementing control measure should be done as soon as
possible
It should go in parallel to investigating the outbreak
Source/ Mode of Transmission

Causative Agent

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Control measures (do early)
1. Measures Directed Against the Reservoir:
 Reduce contact rate
 Reduce infectious sources- destruction of infected animal /isolation
 Reduce infectiousness- early treatment

2. Measures that interrupt the transmission of organisms

 Purification of water
 Pasteurization of milk
 Inspection procedures designed to ensure safe food supply.
 Improve housing conditions

3. Measures that reduce host susceptibility and Increase

herd immunity
- Immunization
- Chemoprophylaxis - Use of antibiotics for known contacts of cases

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Step 10: Communicating findings of investigation
 The final responsibility of the investigative team is to
prepare a written report to document the investigations,
findings and the recommendations
 The written report should follow the scientific reporting format
which includes:
o Introduction
o Methods
o Results
o Discussion
o Conclusion, and
o Recommendations

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 Summary of the investigation and control of an epidemic considering procedure

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Post-Epidemic Surveillance
 The efficacy of control measures should be assessed day by
day during the outbreak, a final assessment being made after it
has ended
 this will provide a logical basis for post-epidemic surveillance,
and preventive measures aimed at avoiding similar outbreaks
in the future
 develop long term early warning system
 monitor environmental risk factors

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The end
Any questions or comments??

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