Screening and Public Health

Surveillance
Our Lady of Fatima University
College of Medical Laboratory Science

Biostatistics and Epidemiology

Screening
Screening
• The presumptive ID of an unrecognized disease or defect by the
application of tests, examinations or other procedures that can be
applied rapidly

• Mainly used to identify ASYMPTOMATIC INDIVIDUALS

• Assumption: Earlier diagnosis leads to earlier treatment

Screening test VS. Diagnostic test

Screening
• Asymptomatic individuals
• Less accurate
• Less expensive
• Not a basis for treatment
Diagnostic
• Symptomatic individuals
• More accurate
• More expensive
• Basis for treatment

Likely to have a
disease
Characteristics of a Disease Appropriate for
Screening
• 1. Disease is serious with severe consequences

• 2. Treatment is more effective at an earlier stage

• 3. Disease has a clinical detectable preclinical stage

• 4. The preclinical phase is fairly LONG and prevalent in the target

population
Characteristics of a Screening Test
• Economical

• Convenient

• Relatively free of risk and discomfort

• Acceptable to a large number of individuals

• Highly valid and reliable

Evaluation of Screening Programs

Feasibility
• Screening programs should be
conducted efficiently, with
minimal inconvenience and
discomfort and at a reasonable
cost
Effectiveness
• Screening programs should
achieve its goal of reducing
morbidity and mortality
Effectiveness of a Screening Program
• Comparison of the survival experience of a screened population with
that of an unscreened population

• Potential systematic errors:

• Volunteer bias
• Lead-time bias
• Length bias
Effectiveness of a Screening Program
• Lead time
• interval between the time of
disease detection
through screening and the time of
disease recognition in the absence
of screening
• Lead time bias
• phenomenon where early
diagnosis of a disease falsely makes
it look like people are surviving
longer
Effectiveness of a Screening Program
• Length time bias
• phenomenon whereby slower-
growing, less aggressive tumors
have a longer preclinical screen-
detectable period and are
therefore more likely to be
screen-detected than faster-
growing, more aggressive cancers
Types of Screening
A. Mass screening: general population

B. Targeted screening: high-risk groups

C. Opportunistic screening: case-finding

D. Multiphasic screening: several screening tools to detect several

conditions at the same time
Multiple Screening Tests
1. Sequential: those who are positive on the first test will be subjected
to the second test

2. Simultaneous: participants are subjected to two or more tests at the

same time
Sources
• US Centers for Disease Control and Prevention. Principles of
Epidemiology in Public Health Practice: An Introduction to Applied
Epidemiology and Biostatistics, 3rd edition
• Sommerville M., et.al. Public Health and Epidemiology at a Glance
• Department of Health-National Epidemiologic Center. Manual of
Procedures for PIDSR
• Bonita R., et.al. Basic Epidemiology, 2nd edition
• Aschengrau A and Seage GR, Essentials of Epidemiology in Public
Health, 2ns edition
Public Health Surveillance
Public health Surveillance
• French: “sur” (over) + “veiller” (to watch)

• A systematic collection, collation, and analysis of data, and the

prompt dissemination of the resulting information to those who need
to know so that action can result.
Purpose of Public Health Surveillance
• Provides and interprets data to facilitate the prevention and control
of disease

• **Should always have clear objectives

• Includes clear description of how data will be used to prevent or control the
disease
 Public Health Surveillance
OBJECTIVE ACTION DATA SYSTEM
Detect epidemics Epidemic response Early warning Active surveillance
information
Monitor intervention Program monitoring Program Health information
program indicators
Monitor impact of Health policy Health indicators Health information
policy change
Monitor health Resource allocation Administrative Health information
system data and management
Utility of Surveillance
A. Immediate detection

B. Periodic Dissemination

C. Stored information
Characteristics of a well-conducted Public
Health Surveillance System
• Acceptability
• Flexibility
• Validity
• Quality
• Representativeness
• Stability
• Simplicity
• timeliness
Essential Activities of Public Health
Surveillance
1. Identify, define, and measure the health problem of interest
2. Collect and compile data about the problem
3. Analyze and interpret the data
4. Provide these data and their interpretation to those responsible for
controlling health problem
5. monitor periodically, evaluate the usefulness and quality surveillance
to improve it for future use.
Defining the Health Problem
• Case definition for surveillance
• Operational definition of the health problem for it to be accurately
and reliably recognized and counted

• Might differ from the following:

• Clinical criteria for diagnosing the disease
• Case definition of the disease used in outbreak investigations
Syndromic Surveillance
• Using less specific criteria

• Used when identifying and counting the occurrence of a disease

consist of a constellation of signs and symptoms, chief complaints or
presumptive diagnosis, rather than the specific clinical or laboratory
diagnostic criteria

• Goal: earlier detection of an unusual increase in illnesses

• Data sources: emergency departments, relies on computer methods

Defining the Scope of Surveillance
• Geographic area

• Population covered

• Time period
Essential Activities of Public Health
Surveillance
1. Identify, define, and measure the health problem of interest
2. Collect and compile data about the problem
3. Analyze and interpret the data
4. Provide these data and their interpretation to those responsible for
controlling health problem
5. monitor periodically, evaluate the usefulness and quality surveillance
to improve it for future use.
Collecting data for Surveillance
• From multiple sources using selected methods

• Understanding the natural history of the disease is critical in

surveillance
• Determines how best to conduct surveillance for the disease
Typical sources of data
• Individual persons • Administrative actions

• Health care providers, facilities • Financial transactions

and records • Sales of goods and services, tax
• Doctor’s clinic, hospital (OPD,ER), • Legal actions
Laboratories
• Environmental conditions
• Air, water • Laws and regulations
Methods of Collecting Health-Related Data
• Environmental Monitoring

• Survey

• Notification

• Registries

• Re-analysis of secondary data

Passive VS. Active Surveillance
Passive
• Health care providers send
reports to health departments
on the basis of a known set of
rules and regulations
Active
• Health departments contact
health care providers to solicit
reports
Sentinel Surveillance
• Relies on a pre-arranged sample of health care providers who agree
to report all cases of certain conditions

• Sample might not be a representative of the entire population

Essential Activities of Public Health
Surveillance
1. Identify, define, and measure the health problem of interest
2. collect and compile data about the problem
3. Analyze and interpret the data
4. Provide these data and their interpretation to those responsible for
controlling health problem
5. monitor periodically, evaluate the usefulness and quality surveillance
to improve it for future use.
Basic Considerations
• Different data imply different types of analysis
• Data from individual cases are analyzed differently form data aggregated

• Descriptive methods are usually appropriate

• Computation of rates of disease or other health-related condition
• Description of the occurrence of disease in terms of person, place and time
• To determine whether the incidence/prevalence has changed

• Selection of data for comparison depends on:

• Health problem, temporal and geographic patterns of occurrence
Analysis by Time
• Purpose: to characterize trends and to detect changes in disease
incidence

• Data organization: tables, graphs or combination

Methods of Analysis by Time
A. Comparison of the number of case reports received for the current
week with the number received in the preceding weeks.

B. Comparison of the number of cases during the current period to the

number reported during the same period for the last 2-10 years

C. Analysis of long-term time trends

Graphing disease occurrence by year
Analysis by Place
• Rates are often calculated by
adjusting for difference s in
population size.
• Rates are usually displayed in a table
or a map
• Chloropleth maps
• Other sophisticated applications
following the advent of geographic
information systems
Analysis by Place and Time
• Disease occurrence is often analyzed by time and place
simultaneously

• Analysis can be organized and presented in

• Tables
• Series of maps highlighting different periods or populations
Analysis by person
• Most common person characteristics
• Age, Sex, Race and ethnicity

• Person variables useful for analysis depending on the health problems

• School or workplace
• Recent hospitalization
• Risk factors for specific diseases
Standard Categorization of age
Childhood Illnesses Pneumonia and influenza Deaths in the elderly
mortality

1-4 <1 65-74

5-9 1-24 75-84

10-14 25-44 ≥85

15-19 45-64

≥ 20 ≥65
Interpreting results of analysis
• Scenario
• Increase in the incidence / variation in pattern of disease

• Response
• Further investigation / prevention or control measures
Common causes of artifactual changes
• Changes in case definition
• Laboratory error
• Duplicate reporting
• Increase in population size
• Ne lab test / diagnostic procedure
• Batch reporting
Essential Activities of Public Health
Surveillance
1. Identify, define, and measure the health problem of interest
2. collect and compile data about the problem
3. Analyze and interpret the data
4. Provide these data and their interpretation to those responsible for
controlling health problem
5. monitor periodically, evaluate the usefulness and quality surveillance
to improve it for future use.
Disseminating Data and Interpretations
• Timely, regular dissemination of basic data and their interpretation is
a critical component of surveillance

• Providers of reports
• Persons, agencies or institutions who use surveillance data for planning or
managing control programs
Essential Activities of Public Health
Surveillance
1. Identify, define, and measure the health problem of interest
2. collect and compile data about the problem
3. Analyze and interpret the data
4. Provide these data and their interpretation to those responsible for
controlling health problem
5. Monitor periodically, evaluate the usefulness and quality surveillance
to improve it for future use.
Purpose of evaluating surveillance systems
• Identifies elements of surveillance that should be enhanced to
improve its attributes

• Improves the quality of data and interpretations provided by

surveillance

• Assesses how surveillance findings affect control efforts

Surveillance Systems in the Philippines
• Phil. Integrated Disease Surveillance and Response (PIDSR)
• Aggregated reports from PIDSR are incorporated into the annual morbidity report of
the Field Health Services Information System
• four major disease surveillance systems prior to PIDSR
• National Endemic Sentinel Surveillance System (NESS)
• hospital-based surveillance system that yields information on admitted cases of
diseases with outbreak potential in sentinel hospitals and which can serve as an
early warning system for epidemics in the community
• VPD Surveillance
• monitoring of priority vaccine-preventable diseases targeted for eradication and
elimination, namely: poliomyelitis, measles and neonatal tetanus
• HIV-AIDS Registry
• keeps track of the number of HIV-AIDS cases through a voluntary testing
program.
• Notifiable Disease Reporting System (NDRS)
• generates information on 17 diseases and 7 syndromes
Approaches of PIDSR
• Facility and community based approaches
• Community
• Barangay health stations
• Rural health units
• City health offices
• Government/private hospitals or clinics
• Government/private laboratories
• Ports and airports
• Case-based data collection
Sources
• US Centers for Disease Control and Prevention. Principles of
Epidemiology in Public Health Practice: An Introduction to Applied
Epidemiology and Biostatistics, 3rd edition
• Sommerville M., et.al. Public Health and Epidemiology at a Glance
• Department of Health-National Epidemiologic Center. Manual of
Procedures for PIDSR
• Bonita R., et.al. Basic Epidemiology, 2nd edition
• Aschengrau A and Seage GR, Essentials of Epidemiology in Public
Health, 2ns edition
Thank you…