SURVEILLANCE

The objectives of the course

After completing the module, participants will improve

knowledge on:

• concept, definition and usefulness of surveillance in

public health

• basic functions

• data management

• support functions

• process of
 components planning
 attributes evaluation
Surveillance — from the French

sur (over) and

veiller (to watch)

— is the “close and continuous observation

of one or more persons for the purpose of
direction, supervision, or control.”
 Surveillance system – Short History

• The Roman Empire - in Western Europe

 health services system
 in a rudimentary form

• In 1348, The Republic of Venice

 decided to hire three public guards

 which had the task of detecting ships in port

having on board sick people and

 preventing disembarkation of that persons

• The disease they were afraid was bubonic plague.

 XVII-th Century

• The existence, acceptance and use

of a diseases classification system
- it was conducted by Sydenham Thomas
- it became functional Sydenham
1624 - 1689

• In 1662, John Graunt,

- he was the first to estimate the population of London
- he made specific mortality analysis (cause of death)
- he provided weekly reports
John Graunt
1620 - 1674

• Applied mathematical analysis

in mortality statistics
(Von Leibniz, 1680) Gottfried Wilhelm
von Leibniz
1646 - 1716
XVIII-th Century

• The term of “statistics” was introduced by Gottfried Achenwall (1740)

• The first health law occurred in the United States (Rhode Island, 1741)

• The sanitary police appeared in Germany (Frank, 1766)

XIX-th Century

• In Europe, the mandatory reporting of communicable diseases

 began in 1881 in Italy and
 in 1890 in the UK
• 1878 – American Congress – authorised “Public Health Service” (PHS)
- to collect reports of the Quarantinable Diseases:
• cholera
• plague
• smallpox
• yellow fever
- the weekly collection of information from 1893.
XX-th Century

• 1901 - cholera, smallpox and TB nominal reporting

• 1910 – polio reporting

• 1918 - flu reporting

• 1935 - the first national health survey in the United States

• 1946 - establishment of Communicable Disease Center (CDC), Atlanta

• 1961 – “MMWR” (Morbidity Mortality Weekly Report) CDC Atlanta

- 52 diseases are reported weekly

• 1968 – WHO –”Surveillance Global Program for Quarantinable Diseases”

 • How might it detect in a mass gathering
 the presence of biologic agents or
 the outbreak of a disease the agent might cause ?

The HEALTH
• How does it learn DEPARTMENT
is responsible • How might it
about cases of
for protecting
communicable track behaviors
the public’s
diseases ? health at increased risk ?

public health
surveillance

CDC. Principles of Epidemiology in Public Health Practice , 3th Edition . 2012

 The Structure of Activity in Public Health

• surveillance
identify
• service
research
- prevention and control programs
and
- program evaluation
service
- epidemiological investigations
needs
• research
- epidemiologic
- behavioural
- laboratory define
training
• training needs
 Definitions

Surveillance is

the ongoing systematic collection, analysis, and interpretation of health data,

essential to the planning, implementation and evaluation of public health practice,

closely integrated with the timely dissemination of these data /information to

those who need to know. (CDC)

The final link in the surveillance chain is the application of these data to
prevention and control.

A surveillance system includes a functional capacity for data collection, analysis,

and dissemination linked to public health programs.

CDC. Principles of Epidemiology in Public Health Practice , 3th Edition . 2012.

Gordis L. Epidemiology. 5th ed.2014
Surveillance
Health Data

COLLECTION
feedback ANALYSIS
INTERPRETATION
DISSEMINATION

PROCESS
with application to Public Health Practice

PREVENTION PLANNING
CONTROL IMPLEMENTATION
EVALUATION

L. Gordis, Epidemiology. 5th .2014

CDC. Comprehensive Plan for Epidemiologic surveillance . Atlanta, GA, 1996
S.B. Thacker in S.M. Teutch & R.E. Churchil. Principles and Practice of Public Health Surveillance. 1994
 Data collection
• ongoing
• systematic
• long term Methods are
distinguished
• active by

Gordis L. Epidemiology. 5th ed.2014

CDC. Comprehensive Plan for Epidemiologic surveillance . Atlanta, GA, 1996
S.B. Thacker in S.M. Teutch & R.E. Churchil. Principles and Practice of Public Health Surveillance. 1994
 By observing trends in …

Time Place
… changes can be
• observed or
• anticipated and …
Persons

… appropriate actions
can be taken, including
- investigative or
- control measures

Gordis L. Epidemiology. 5th ed.2014

CDC. Comprehensive Plan for Epidemiologic surveillance . Atlanta, GA, 1996
S.B. Thacker in S.M. Teutch & R.E. Churchil. Principles and Practice of Public Health Surveillance. 1994
 Data dissemination

• must be done
 timely
 periodically

 to those
• who need to know
• who may apply them
 to prevention
 to control
 disease
 injury

Gordis L. Epidemiology. 5th ed.2014

CDC. Comprehensive Plan for Epidemiologic surveillance . Atlanta, GA, 1996
S.B. Thacker in S.M. Teutch & R.E. Churchil. Principles and Practice of Public Health Surveillance. 1994
 • identify the health
• define problem of
• measure interest
 about the problem
• collect data
 about the factors
• compile data
that influence it (if possible)

Persons
• analyze
conducting
• interpret these data
surveillance
should
• provide
- to those responsible
 these data and for controlling the
 their interpretation health problem

• monitor and  usefulness - to improve it

• evaluate periodically  quality of surveillance - for future use

Note that surveillance of a problem does not include actions to control the problem !
CDC. Principles of Epidemiology in Public Health Practice , 3th Edition . 2012
 surveillance

Determinant
factors
health
effects related
Risk
factors events

• frequency
• severity
 their measurement is useful
• impact
 they are more frequent than effects

 they are more precisely established

for small populations

 they are linked to public health

interventions
 Differences Medical surveillance
• identify contacts of patients with
infectious disease
Epidemiological surveillance
• it runs within the maximum
• active
incubation period of the disease
• timely
• early detection of disease signs
• identify problems
for research
• disseminates the results Epidemiological research
periodically • not timely
• connection with • limited dissemination of results
epidemiological action • limited connection with
epidemiological action
• may be based on surveillance

Medical information systems

• may not be active
• may not disseminate regularly the results
• do not apply data in specific epidemiological action
• data may be useful in surveillance
 THE USES OF SURVEILLANCE

1. Quantitative estimates of the magnitude of a health problem in the

population at risk

2. Portrayal and understand of the natural history of disease or injury

3. Detection of outbreaks or epidemics

4. Documentation of the distribution and spread of a health event

Thaker SB. Historical development in Teutsch SM & Churchill RE. Principles and Practice of Public Health Surveillance. 2000.
 THE USES OF SURVEILLANCE

5. Facilitating epidemiologic and laboratory research, identifying

research needs

6. Testing of hypotheses about etiology

7. Evaluation of control and prevention measures / strategies

8. Monitoring of changes in infectious agents

9. Monitoring of isolation activities

10. Detection of changes in health practice

Thaker SB. Historical development in Teutsch SM & Churchill RE. Principles and Practice of Public Health Surveillance. 2000.
 THE USES OF SURVEILLANCE

11. Assess the quality of health care

12. Assess the safety of drugs or procedures

13. Facilitation of planning

14. Prioritize allocation of health resources

15. Forecasting or predicting the future patterns of diseases

Thaker SB. Historical development in Teutsch SM & Churchill RE. Principles and Practice of Public Health Surveillance. 2000.
 Steps in Planning a Surveillance System

1. Establish objectives

2. Develop case definitions

3. Determine data source or data collection mechanism

(type of system)

4. Develop data collection instruments

5. Field test methods

6. Develop and test analytic approach

7. Ensure use of analysis and interpretation

8. Develop dissemination mechanism

Teutsch SM. Considerations in Planning a Surveillance Sysyem. in Teutsch SM & Churchill RE. Principles and Practice of Public Health Surveillance. 2000
 Criteria for Selecting High-Priority Health Events for Surveillance

Public health importance of the problem:

• frequency: incidence, prevalence, mortality
• severity: case-fatality ratio, hospitalization rate, disability rate, sequela,
years of potential life lost, quality-adjusted life years lost
• socioeconomic impact: costs direct and indirect
• communicability
• potential for an outbreak
• public interest: perception and concern
• international requirements

Ability to prevent, control, or treat the health problem:

• preventability
• control measures and treatment

Capacity of health system to implement control measures for the health problem:
• speed of response
• economics
• availability of resources
• what surveillance of this event requires

Teutsch SM. Considerations in Planning a Surveillance Sysyem. in Teutsch SM & Churchill RE. Principles and Practice of Public Health Surveillance, 2000
CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012
Characteristics / Attributes of Surveillance

1. Acceptability
2. Simplicity
3. Quality
4. Flexibility
5. Sensitivity
6. Predictive Value Positive
7. Representativeness
8. Stability
9. Timeliness
10. Validity

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012

 Characteristics / Attributes of Surveillance

Acceptability reflects the willingness of

• individual persons and
• organizations to participate in surveillance.
Acceptability is influenced substantially by
• the time and effort required
 to complete reports and
 submit reports or
 perform other surveillance tasks.

Simplicity refers to the ease of operation of surveillance

• as a whole and
• of each of its components
e.g.
 how easily case definitions can be applied or
 how easily data for surveillance can be obtained

The method for conducting surveillance

• typically should be as simple as possible
• while still meeting its objectives.
CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012
 Quality reflects
• the completeness and
of the data used
• validity for surveillance.

One simple measure of quality is the percentage

(in the data used for surveillance)
• of unknown or
for a particular variable (e.g. age)
• blank values

Flexibility refers to the ability of the method used for surveillance

• to accommodate changes
 in operating conditions or
 information needs
• with little additional cost
 in time
 personnel
 funds

Flexibility might include the ability of an information system,

 whose data are used for surveillance of a particular health condition,
 to be used for surveillance of a new health problem.

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012

Sensitivity is the ability of surveillance
• to detect the health problem
• that it is intended to detect.
Surveillance, for the majority of health problems,
• might detect a relatively limited proportion
• of those that actually occur.
The critical question is whether surveillance
• is sufficiently sensitive to be useful
• in preventing or controlling the health problem.

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012

Predictive Value Positive is
• the proportion of reported or identified cases that truly are cases, or
• the proportion of reported or identified outbreaks that were actual outbreaks.

Conducting surveillance that has poor predictive value positive is wasteful,

• because the unsubstantiated or false-positive reports
 result in unnecessary investigations,
 wasteful allocation of resources, and
• especially for false reports of epidemics,
 unwarranted public anxiety

Principles of Epidemiology in Public Health Practice, third edition, CDC

 Representativeness is the extent to which
• the findings of surveillance accurately portray the incidence of a health event
among a population by person, place, or time.

• Representativeness is influenced by the acceptability and sensitivity of the

method used to obtain data for surveillance.

• Too often, epidemiologists who calculate incidence rates from surveillance

data, incorrectly assume that those data are representative of the population.

Stability refers to
• the reliability of the methods for obtaining and managing surveillance data
• to the availability of those data.
This characteristic
• is usually related to the reliability of computer systems that support
surveillance but
• might also reflect the availability of resources and personnel for conducting
surveillance.

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012

 Timeliness refers to
 the availability of data rapidly enough
 for public health authorities to take appropriate action.
• Any unnecessary delay in
 the collection
 management
 analysis
 interpretation
 dissemination of data for surveillance
• might affect a public health agency's ability
 to initiate prompt intervention or
 provide timely feedback.

Validity refers to
 whether surveillance data are measuring
 what they are intended to measure.
• As such, validity is related to
 sensitivity and Is surveillance detecting the
 predictive value positive outbreaks it should?

Is it detecting any non-outbreaks?

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012
Relative importance
of selected surveillance characteristic
by use of surveillance findings

CDC. Principles of Epidemiology in Public Health Practice, 3rd edition, 2012

 Surveillance - Reporting
Case definition:
– simple,
– acceptable,
– easy to understand,
– standardized for all reportable diseases,
– could be published

Criteria
– clinical
– laboratory
– epidemiological
Population Authorities

Principles of Epidemiology in Public Health Practice, third edition, CDC

Surveillance system

Medical Personnel Data Sources

Authorities Health care
Population providers

Public
Health
Agency
 DATA SOURCES

I. Mortality data

II. Morbidity data

III. Health studies in general population

IV. Surveillance systems of

disease indirect indicators
I. Mortality data
1. Vital Statistics

- birth
- death • useful only for illnesses
- marriage associated with fatalities
- divorce
• could provide an estimate of
the actual number of cases
2. Data are provided by

- coroners
- anatomo-pathologist
- medical examination records

wide variation in the accuracy of reporting

II. Morbidity data

1. Reporting of notifiable diseases

• any outbreak
• acute infectious disease cases
• chronic and non-communicable disease cases

* an accurate and prompt reporting is required

* individual case reporting is not practical for

high frequency cases in epidemics
 II. Morbidity data

2. Laboratory data could be

• part of the reporting system of notifiable diseases
• an independent reporting

* essential in confirming pathogens

* can provide information concerning specific characteristics of

microorganisms
e.g. - composition of influenza vaccine for the next season
- acquired resistance:
MRSA - Methycilin-resistant Staphylococcus aureus samples
VRE - Vancomycin resistant Enterococi
MDRTB – multi-drug resistant tuberculosis
XDR TB - extensively drug-resistant tuberculosis

* important in evaluating programs, by serological investigation

(e.g. immunization program)
 II. Morbidity data
3. Data from hospital

 records of discharges
• demographics data
• diagnoses of reporting infectious diseases from
 hospitalized patients and
 outpatients
• surgical procedures
• length of stay
• costs
 could provide information regarding
 community and
 hospital acquired infections
(nosocomial infections)
 national data can be
• complete or
• based on a national randomized sample of hospitals
II. Morbidity data
4. Ambulatory care patients
• individual medical offices
• diagnosis and treatment centers

Can be used
• randomized samples of offices
• a network of general practitioners interested in
that health condition

5. Specific sources
• cancer registration
• adverse drug reactions
• injury surveillance systems
• occupational disease records
III. Surveys in general population

 sampling

 could provide information concerning

• nutritional status
• various diseases prevalence
 clinical survey
 diagnostic tests (e.g. skin tests)
 serological profile (e.g. serological tests)
• disability
• use of health care services
• behavioural risk factors
 IV. Indirect indicators of disease

1. animal population
• animal reservoir and
• vector distribution studies
 essential in maintaining surveillance
 of zoonotic and arthropod-borne diseases
early
warning
systems
2. data about the environment are useful
• to analyze disease occurrence
• to establish information in order to identify
source of infection,
transmission way
 IV. Indirect indicators of disease

3. the distribution of drugs and biological products

 for prophylaxis and
 treatment
• could be used to monitor disease occurrence

4. the absence of pupils, students and employees

5. news media information

• it’s not uncommon for the occurrence of an epidemic
to be first noted by the media
Data Collection

Passive

Active

Sentinel

Data base available

 Passive surveillance

• Surveillance of most routine

• Public Health Agency
reporting disease is based on
expects health care
passive reporting.
providers to report
cases.
• It operates on a set of
published laws and
regulations.

• Advantages:
•Disadvantages:
 worldwide spread
people with other activities
 cheap - without additional resources
 simple  underreporting
 easy to operate with  incomplete data
him at the Public Health  variability
Agency level  sometimes unrepresentative
 sometimes unable to identify
the outbreaks
 Active surveillance
It usually involves expanding to
• Health agency requires regularly potential rapporteurs to
health care providers to specify stimulate disease reporting
whether they saw cases of a given
health condition.

It is based on
certain regulations

• Advantages:
 validate if the passive reports are representative
 provide better reporting of health conditions,
 field visits
- to identify new cases or deaths
- reviewing medical records Disadvantages
● costly
 interviews with physicians or patients
● difficult to initiate
 can be used in specific epidemiological ● for short periods
investigations ● for conditions of particular
 can be used in routine medical surveillance or importance
from an index case ● identifying local outbreaks
 individuals especially employed
accuracy
 Sentinel system
Advantages

Sample alternative to passive systems

• predetermined relativly sensitive for
• homogeneous  early detectin
• well defined  monitoring
• specific areas simple
• nonrandomly selected
• consisting of reporting sources
 that are likely to encounter cases
 that accept to report

Disadvantages
underreporting
(not representative))
• interpretation problems
 Databases available

• economic data

• reduced medical content

• anonymous

• the community level

• already processed

• they are not recent anymore

• their secondary use is more appropriate to guide

long-term interventions

• data quality may be low

• the strategy can be a primary approach

 Analysis time – place - person

different data  different analyzes

individual data  aggregate data

text data  encoded data

sample data  weighted

descriptive method  frequencies tables

rates graphics

Rates
allow comparisons  between areas or
time periods
denominator  general population
population at risk

CDC. Principles of Epidemiology in Public Health Practice , 3th Edition . 2012

Analiza
Surveillance
Time
Patern • Collection Place
• Analysis Person

• Interpretation

• Disease occurrence Excess

Changes • Evolution of
• Potential cases

Action
CDC. Principles of Epidemiology in Public Health Practice , 3th Edition . 2012
 Analysis
It compares the obtained values with the "expected" values
Identify in what way and how much they differ
It is estimated the importance of the difference

“Expected” values
Figures from the latest/recent reporting period

4w 3w 2w 1w present

Figures of the corresponding period of

previous years
2015
2014
2013
2012
 Calculation of 5 years weekly average
(e.g. for week 36 of 2015)

Week number

Anul 34 35 36 37 38

2015 Current week

2014 X1 X2 X3 X4 X5
2013 X6 X7 X8 X9 X10
2012 X11 X12 X13 X14 X15
2011 X16 X17 X18 X19 X20
2010 X21 X22 X23 X24 X25

sum of incidences in weeks X1 – X25

The 5 years weekly average =
25
 Analysis
It compares data from an area with data
from surrounding areas.

County

neighboring
counties
Country

County

It compares data from an area with data

from a larger area to which it belongs.
 Data interpretation

obtained data ≠ expected pattern

excess of cases The rise of the case number

• real
• apparent

• small number

initiation of the action

 Data interpretation

Starting the action depends on

• priority of the disease
• interests
• capacities of the department
• resources

The investigation • is suspected a common source

sometimes starts
with a small • emergent / reemergent disease
number of cases
• media, politics, public pressure
 Data interpretation

• the increase in size of the population

• case definition change (e.g
(e.g.,
., TB as AIDS defining illness)
• improving diagnostic procedures
Apparently
increase of • reporting voluntary / mandatory
the number • double reporting
of cases
• numerical / nominal reporting
• changing the reporting period (week, month, quarter)
• warning of physicians
• warning of population
 Dissemination of findings

Presentation of the
conclusion shoud be
• concise
• clear
• convincing The public access to data
should take into account
• the patient privacy
• the data confidentiality
• the security of the system

The messages to health care

professionals should be
accompanied by
• analysis of data
• interpretation
• recommendations
 Dissemination of findings

audience characteristics
nature of the information
how could the audience
use the information

the choice of the

communication
system variant

information
motivation amplification
of formulated
messages
 Evaluation

It is focused on
the good
functioning of
the system.
The scope of the assessment
is the ensuring that important public health
issues were effectively and efficiently monitor.

Highlights of the evaluation are

• the beneficiaries of the system
• the importance of the condition for the public health
• the purpose and the objectives of the system
• the operating mode of the system
• the resources used
• the usefulness of the system
• the attributes of the system
 Evaluation

Systems The
varies importance
• purpose of attributes
• goals varies by
• methods the system
 Evaluation

• it is periodically performed
• it includes recommendations

• prompt changes
• system improvement
 quality
 efficiency
 utility
The connection with public health action

Public health
agency

Surveillance Public health

system programme

Communicable
The diseases action
functional
link
Chronic
diseases
action
The critical point

of surveillance is

ensuring its

usefulness.