PUBLIC HEALTH SURVEILLANCE

Medhin Mehari (BSc, MPHE)

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 Learning Objectives
• Explain the purposes of public health surveillance
• Compare and contrast the various methods of public health
surveillance
• Describe the criteria for evaluating surveillance system

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 Contents
• Definition, purpose
• Activities
• Methods: active, passive, sentinel
• Evaluation

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 References
• Principles of Epidemiology in Public Health Practice: An
Introduction to Applied Epidemiology and Biostatistics, 3rd ed.
CDC: U.S.A, 2006.
• Guideline on Public Health Emergency Management. EHNRI:
Addis Ababa, 2012.
• Teutsch SM, Churchill RE. Principles and Practice of Public Health
Surveillance, 2nd ed. Oxford University Press, 2000.

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Definition
Surveillance is
• a continuous and systematic monitoring of diseases and/or
determinants
– through collection, analysis and interpretation of data and
dissemination findings
– for prevention and control of diseases
• Surveillance is an on-going systematic approach
• It is “Information for Action”

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Purposes of surveillance (1)
• To describe magnitude and distribution of disease
– Useful for planning health services
• To detect sudden changes in disease occurrence
– for early recognition and control of epidemics
• To identify changes in agents and host factors
– enables to assess the potential for future disease
occurrence

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Purpose of surveillance (2)
• To compare extent of the problem before and after
intervention
– For evaluating prevention and control measures
• To generate hypotheses
– stimulate public health research

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Information for Action

Surveillance Public Health Action

Collection Investigation of epidemics
Analysis Planning and evaluation of
Interpretation  Health programs
Dissemination

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 Selection Criteria for Disease Surveillance

1. Magnitude of the disease

2. Feasibility of control measures
3. Need for monitoring and evaluating the
4. performance of a control program
5. Resource availability

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Activities in Surveillance
• Core
– Data collection: primary or secondary data
– Data compilation and reporting
– Data analysis and interpretation
– Dissemination of information for action
• Supportive
– Supervision
– Feedback

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Methods of Surveillance
There are three major types/approaches of surveillance:
• Passive Surveillance
• Active Surveillance
• Sentinel Surveillance

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Passive surveillance
• Uses data collected as part of the routine passive case
detection and recording
– The information provider comes to the health institutions
seeking health service
• Bases on reporting from all health facilities in a country
– universal case reporting
• This method has the advantages of and suffers from the
limitations of using health service records as source of data

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Advantages of passive surveillance

• relatively cheap
– does not require special arrangement
• covers a wider area
• covers a wide range of problems

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Disadvantages of passive surveillance

• The data may be incomplete and inaccurate

• Lacks of timeliness mainly due to late reporting
• Lack of representativeness of data
• The kind of information desired may not be obtained

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 PHEM
• PHEM is the process of
– anticipating,
– preventing,
– preparing for,
– detecting,
– responding to ,
– controlling and
– recovering from consequences of Public Health
threats in order that health and economic impacts are
minimised;
 Institutional
PHEM Process
framework

Vulnerability Assessment Public Health

and Risk Mapping Intelligence

Public Health
Planning Emergency Early Warning Communication
Preparedness

Capacity Monitor and Evaluate

Building

Monitor and
Rehearse
Public Health Emergency
Management

Outbreak investigation/Rapid
Assessment

Public Health Rehabilitation

Control and Prevention Emergency
measures Recovery
Response
Evaluation

Monitor and Contain

 Goal of PHEM

• To markedly reduce mortality and morbidity

due to epidemics and other Public Health
Emergencies and minimize associated social
and economic crisis
 Priority diseases for PHEM in Ethiopia

Priority diseases are diseases that fulfil one or more of the criteria
• They have a high potential for causing epidemics
• They have been targeted for eradication or elimination
• They have significant public health importance (causing many
illnesses and deaths)
• They can be effectively controlled and prevented.

 Thus, PHEM is a cost-effective surveillance system which

addresses the major health problems of Ethiopia.
 List of immediate ad weekly reportable diseases reportable
diseases in Ethiopia
(find the update one)

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 Public Health Emergencies
1. Epidemics of communicable disease
2. Drought with malnutrition
3. Food contamination
4. Flood
5. Pandemic Influenza
6. Conflict and displaced populations
7. Accidents incl. chemical spills
8. Earthquake, volcano
9. Bioterrorism
 Surveillance flow chart
Legend
Upward
National level transmission of
reports, data &
information
Feedback and
Region/Zone information
sharing

Hospital Private,NGO,and
Woreda
other health facility

Community health facility Community

Community
Timeline for immediately notifiable diseases/conditions
Zone Region
Health EPHI
Facility Woreda

Within 30 Within 30
Within 30 Within 30 Minutes
Minutes
Minutes Minutes

Event
0:30 1:00 1:30 2:00

Time
Timeline for weekly reportable diseases/conditions

HF to Woreda Zone to Region to

woreda to zone Region EPHI

Event Monday Tuesday Wednesday Thursday

The following Week

 Surveillance data reporting methods
EPHI

E-mail
Fax
Rumor-
Region
Phone
Telephone
E-mail
Zone Fax

Telephone
Woreda Fax

Health • Paper
Facility • Telephone

Papers Telephone E-mail

 Active surveillance

• Uses primary method of data collection usually on a specific

disease, for relatively limited period of time
– Example: during investigation of outbreaks
• It involves collection of data through:
– House-to-house surveys or
– Mobilizing communities to some central point where data
can be collected

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Advantages and disadvantages of active
surveillance
• Advantages
– the collected data is more complete and accurate
– the collected data is timely
• Disadvantages
– it is expensive
– requires skilled human power
– hence, applied for short duration and directed
towards specific disease conditions

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Applications of active surveillance
• For periodic evaluation of an ongoing program
• For programs with limited time of operation such as
eradication programs
• In unusual situations such as
– Discovery of new disease, new mode of transmission, new
affected subgroup or new season of occurrence
– When a previously eradicated disease reappears
• E.gs. – active surveillance in Ethiopia?
– Epidemic investigation, polio surveillance,

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 Sentinel Surveillance

• uses a pre-arranged sample of reporting sources to report all

cases of one or more conditions
• This is carried out by:
– Selecting sample sources/institutions most likely to see cases
of the specified condition
– Sentinel surveillance provides a practical alternative to
population-based surveillance, in developing countries
• E.g. ANC sentinel surveillance

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Advantages and disadvantages of sentinel surveillance

• Advantages
– relatively inexpensive
– provides a practical alternative to population-based
surveillance
– can make productive use of data collected for other
purposes
• Disadvantages
– the selected population may not be representative of the
whole population
– use of secondary data may lead to data of lesser quality
and timeliness

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 Elements of a surveillance system
• Case definition
• Indicators
• Population under surveillance
• Cycle of surveillance
• Confidentiality
• Incentives to participation

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 Case definition

 Case definition
• It 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
Classification of case definition
1. Confirmed: a case definition by appropriate lab. 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.
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 Case definition……..
 Measles Case Definition
Clinical measles = suspected case:
• Fever AND rash AND at least one of the “3 Cs” –
cough, conjunctivitis or coryza
• Measles suspected by a clinician
Confirmed measles case:
• Lab confirmed: measles IgM positive
• Epidemiologically linked

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 Case definition……..
Major advantages of case definition
1. Facilitate early detection and prompt management of
cases
2. Useful in areas where there is no laboratory
3. Facilitate observation of trends
4. Facilitate comparison more accurately from area to area

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 Evaluation of Surveillance System (1)
Purpose: to identify areas for improvement

Components to be evaluated and criteria:

• Relevance: evaluate public health importance

– incidence, prevalence, severity, mortality, preventability,
potential for spread
• SMARTness of the objectives
• Effectiveness – evaluate system attributes
– simplicity, flexibility, acceptability, sensitivity, predictive value
positive, representativeness, timeliness
• Cost : resource required to operate the system
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 Evaluation of Surveillance System
Acceptability
• Willingness of persons conducting surveillance and those providing
data to generate accurate, consistent and timely data.
Representativeness
• The degree to which inference can be drawn from the information
gathered by the surveillance system to the target population
Reporting Completeness
• Proportion of all expected reports in a reporting system that were
actually received.
Reporting Timeliness
• Proportion of all expected reports in a reporting system received by
a given date (due date).
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 Evaluation of Surveillance System (2)
Performance/implementation: assess operation of the
system

-Timeliness of reporting, completeness of data,

comprehensiveness of reporting sources, performance in
data analysis, dissemination of findings
-Availability of trained human power, support
activities and material resources

• Outcome – evaluate usefulness

• Outbreaks investigated, plans and evaluations done
using the surveillance information

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 Attributes of a good surveillance system
• Simple
• Flexible
• Acceptable
• Sensitive; able to detect the problem
• Good predictive value positive; good yield
• Representative
• Timely
• Cost effective

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Common Limitations of Surveillance Systems
1. Under reporting
2. Lack of representativeness of reported cases
3. Lack of timeliness
4. Inconsistency of case-definitions
5. Lack and shortage of qualified staff
6. Lack of motivation

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THANK YOU

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