Surveillance

Abdullatif Husseini, MSc, MPH, PhD

 IMPORTANT NOTE
YOU CANNOT DEPEND ON READING THE SLIDES
ONLY. YOU NEED TO READ THE RELEVANT
CHAPTERS IN YOUR TEXT BOOKS (Gordis 2014 &
Bonita, 2006) AND ALL REQUIRED READINGS IN
YOUR SYLLABUS TO UNDERSTAND THE TOPIC.
THANK YOU
 Learning outcomes:
• By the end of the session/s students should be
able to:
– Describe the importance of disease surveillance
– Define the scope of surveillance
– Identify the objectives of a surveillance system
– Outline the main uses of surveillance
– Differentiate between passive and active
surveillance
– Discuss the evaluation of a surveillance system
https://www.facebook.com/ThisIsPublicHealth/
 DEFINTION
“Epidemiologic 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 to those
who need to know.
The final link in the surveillance chain is the application
of these data to prevention and control. A surveillance
system includes a functional capacity for data collection,
analysis, and dissemination linked to public health
programs”

(Thacker et al, 1988.)

 The word surveillance:

• Is derived from the French word “surveiller”

which means to watch over. This includes
both notions of careful observation and
timely intervention

Schewara, 2012
 What is surveillance?
• “Surveillance is a fundamental role of public
health.
• Surveillance may be carried out to monitor
changes in disease frequency or to monitor
changes in the levels of risk factors.
• Much of our information about morbidity and
mortality from disease comes from programs
of systematic disease surveillance.”
Gordis, 2014
 Surveillance today
• Traditionally epidemiological surveillance was
focused on infectious diseases.
• Over time, surveillance has expanded to encompass
non-infectious conditions such chronic diseases,
injuries, and environmental and occupational
exposures, as well as personal behaviors that
promote health and prevent disease.
 Objectives of surveillance 1:
1. Early detection of changes in disease
patterns and risk factors to enable
appropriate actions
2. Description of basic epidemiology ( e.g.
natural history) of a disease
3. Links epidemiological changes and disease
trends to health services and research
4. Forecast trends in disease frequency
5. Early warning of epidemics
 Objectives of surveillance 2
5. Monitoring trends in disease, microbial
agents and risk factors to:
a- asses priorities for intervention
b- evaluate control and prevention programs
c- monitor changes in infectious diseases
d- detect changes in health practices or medical care
e- facilitate planning
6. Identify the emergence of new diseases
7. Identify risk factors
 Components of a surveillance system

• Population under surveillance

• Clear and standardized case definitions
• Complete surveillance cycle especially a
functional reporting system
• Ethical considerations especially
confidentiality
• Incentives for participation
 Characteristics of surveillance
• Usefulness • Simplicity
• Relevance • Accuracy
• Representativeness • Timelessness
(specificity) • Flexibility
• Completeness • Acceptability
(sensitivity)
 Uses of a surveillance system

• Planning health • Identifying and

programs monitoring risk
• Detection of health factors
problems • Identifying epidemics
• Monitoring and • Monitoring health
evaluating services measures
interventions • Effective
• Identifying high risk communication
groups
Uses of Surveillance

Bonita et al, 2006

 Examples on the use of
surveillance information

1. Planning health programs: information on the

magnitude and geographical distribution of
meningitis caused by hemophilus influenza will
help in planning a vaccination program
2. Detection of health problems: same as above
3. Monitoring and evaluating interventions: was
there a significant decrease in the incidence of
meningitis after introducing the vaccination
program
 Examples- Cont
4. Identifying high risk groups: children
5. Identifying and monitoring risk factors: contact
with infected people
6. Identifying epidemics: an epidemic on the southern
parts of the West Bank
7. Monitoring health services measures: are there
enough coverage of the vaccination?
8. Effective communication: are the important
information provided to all stakeholders?
 Types of epidemiological
surveillance

• Disease surveillance

• Population data
 Surveillance approaches
• Passive (provider initiated) routine surveillance
• Active (health department initiated) routine
surveillance
• Sentinel-site surveillance (monitoring of key health
events through sentinel: sites, providers, events, and
vectors/animals)
• Outbreak investigation: an active process for early
detection of causes and prevention of outbreaks
 Criteria for selecting diseases to be
included in the surveillance system
• “Conditions for which surveillance can effectively lead to
prevention.
• Surveillance systems should reflect the overall disease
burden of the community.
• Incidence and prevalence
• Indices of severity (case-fatality ratio)
• Mortality rate and premature mortality
• An index of lost productivity (bed-disability days)
• Medical costs
• Preventability
• Epidemic potential
• Information gaps on new diseases.”

Bonita et al, 2006

 Approaches- Cont

• Registries: listings of all occurrences (relatively

detailed information) of a disease, or category of
disease within a defined area (e.g. national cancer
registry)
• Repeated regular surveys: provide a method for
monitoring changes in behaviors and personal
attributes that affect disease risk, knowledge
/attitudes that influence health behaviors, use of
health services, and self-reported disease
occurrence
Passive & Active surveillance HERE
Passive surveillance
• “denotes surveillance in
which available data on
reportable diseases are
used, or in which disease
reporting is mandated or
requested, with the
responsibility for the
reporting often falling on
the health care provider or
district health officer.”
Active surveillance
• “denotes a system in which
project staff are recruited to
carry out a surveillance
program. They are recruited
to make periodic field visits
to health care facilities such
as clinics and hospitals in
order to identify new cases
of a disease or diseases or
deaths from the disease that
have occurred (case finding).”
Gordis, 2014
Issues Regarding Passive Surveillance
• Completeness and quality of the data
• Largely depend on staff already working in the
system and does not require costly additional
resources
• Underreporting & incomplete reporting
• “Reporting instruments must be simple and
brief”
• Relatively inexpensive and easy to develop
Gordis, 2014
 Issues Regarding Active Surveillance
• Usually more expensive
• Uses devoted personnel to actively collect
data form the filed compared to existing staff
in passive surveillance
• “may involve interviewing physicians and
patients, reviewing medical records”
• More difficult to develop initially compared to
passive surveillance
Gordis, 2014
Disease Sources of Information
• Disease notification
• Morbidity and mortality registration
• Health unit based surveillance
• Population based surveillance
• Laboratory based surveillance (e.g. new subtypes of flu,
or serotypes of Salmonella)
• Other data sources such as:
– Vaccination adverse reaction records
– Drug utilization records
 Sources of data
• “mortality and morbidity reports
• hospital records
• laboratory diagnoses
• outbreak reports
• vaccine utilization
• sickness absence records
• biological changes in agent, vectors, or reservoirs
• blood banks.”
Bonita et al, 2006
Natural History of Disease
Disease progression
 Population data sources

– Vital statistics (birth & death registration)

– Usage of service (e.g. bed occupancy in

hospitals)

– The community
 Analysis of surveillance data

 Analysis of surveillance is usually performed

using simple descriptive statistics and standard
epidemiologic techniques

 In some cases group comparisons may require

steps more advanced techniques such as
bivariate and multivariate analysis
 Analysis - Cont
• Done on regular and ongoing basis
• Special analyses when disease outbreaks or unusual
health conditions occur
• Results from data analyses should be reviewed
regularly, and reported back to those who originally
reported the information
• Summaries of data analyses should also be reported to
policy makers and intervention program planners

Adapted from Ching

 Data presentation

• The classical general methods of data

presentation are used in presenting
surveillance data. Those include:
– Written summaries
– Tables
– Graphs
An example of data presentation
Another example of data presentation
Evaluation of a surveillance system

Does the system:

1. detect trends signaling new problems?
2. detect epidemics?
3. give appropriate information on the distribution of
health events (sex, age, geographical, ...etc.)?
4. provide magnitude estimates of mortality and
morbidity?
5. identify risk factors?
6. facilitate research?
 Surveillance challenges in developing
countries
• “Some areas that needs surveillance may be
difficult to reach
• Lack of a functional communication system with
policy and decision makers who decide on
resource allocation for disease control and
prevention
• Case definitions for some disease may be
inappropriate
• or useless due to the lack of diagnostic facilities
for suspected cases
• This may result in underreporting of cases”
Gordis, 2014
“ Good surveillance does not
necessarily ensure the making of
right decisions, but it reduces the
chances for wrong ones”

Alexander D. langmuir
 References:
• Gordis L, 2009. Epidemiology, 5th ed. Philadelphia: Elsevier
Saunders.
• Bonita R, Beaglehole R, Kjellstrom T, 2006. Basic
Epidemiology. Geneva: WHO.
• Thacker SB, Berkelman RL. Public health surveillance in the
United States. Epidemiologic reviews. 1988;10:164-90.
• Schwerha J. Medical Surveillance. SUPERCOURSE PPT
presentation, 2012.
• Ching P. Analysis, Reporting, and Feedback of Surveillance
Data part I&II. SUPERCOURSE PPT presentation, 2012.
• Other SUPERCOURSE PPT presentations.