American Journal of Epidemiology Vol. 183, No.

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February 26, 2016

Commentary

The Development of Surveillance Systems

D. A. Henderson*

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* Correspondence to Dr. D. A. Henderson, 1055 West Joppa Road, Towson, MD 21204 (e-mail: dahzero@aol.com).

Initially submitted August 4, 2015; accepted for publication August 21, 2015.

Surveillance systems in public health practice have increased in number and sophistication with advances in data
collection, analysis, and communication. When the Communicable Disease Center (now the Centers for Disease
Control and Prevention) was founded some 70 years ago, surveillance referred to the close observation of individ-
uals with suspected smallpox, plague, or cholera. Alexander Langmuir, head of the Epidemiology Branch, redefined
surveillance as the epidemiology-based critical factor in infectious disease control. I joined Langmuir as assistant
chief in 1955 and was appointed chief of the Surveillance Section in 1961. In this paper, I describe Langmuir’s re-
definition of surveillance. Langmuir asserted that its proper use in public health meant the systematic reporting of
infectious diseases, the analysis and epidemiologic interpretation of data, and both prompt and widespread dissem-
ination of results. I outline the Communicable Disease Center’s first surveillance systems for malaria, poliomyelitis,
and influenza. I also discuss the role of surveillance in the global smallpox eradication program, emphasizing that
the establishment of systematic reporting systems and prompt action based on results were critical factors of the
program.

epidemiologic surveillance; influenza, human; malaria; poliomyelitis; public health surveillance; smallpox

Abbreviations: CDC, Centers for Disease Control and Prevention; USAID, US Agency for International Development; WHO, World
Health Organization.

Programs of surveillance are proving to be of increasing THE CONCEPT OF SURVEILLANCE

value in public health practice. They have increased steadily
in number and sophistication as systems for data collection,
analysis, and communication have grown. Surveillance pro-
grams have assumed such a central role in planning and eval-
uation that they have been termed “the foundation of all
public health practice” (1, p. 30).
The importance and relevance of surveillance is illustrated
by the key role it played in the achievement of smallpox erad-
ication (2). That program, begun in 1967, concluded in 1980
with the declaration by the World Health Assembly that
global eradication had been achieved. The core component
of its strategy was surveillance, as proposed in the Director-
General’s Report to the World Health Organization (WHO)
in 1966 (3). To grasp the importance of surveillance in small-
pox eradication, it is important to understand the origin of its
definition and use, something of its early applications, and fi-
nally its practical utility in the smallpox program itself.
The Centers for Disease Control and Prevention (CDC)
was founded 70 years ago as the Communicable Disease
Center, the postwar successor to the Office of Malaria Con-
trol in War Areas. Its founders intended its responsibilities
to eventually broaden to include a national public health
agenda that encompassed all infectious diseases. Alexander
Langmuir, associate professor of epidemiology at the Johns
Hopkins University School of Hygiene and Public Health
(now the Bloomberg School of Public Health), was selected
in 1949 to be director of the new agency’s Epidemiology
Branch. For him, surveillance was the critical public health
factor for infectious disease control. It was a new concept;
its basis was epidemiology.
I joined Langmuir as assistant chief in 1955 (Figure 1),
having decided that fulfilling my 2-year national service re-
quirement would prove more interesting in the Public Health

381 Am J Epidemiol. 2016;183(5):381–386

382 Henderson
Figure 1. Alexander Langmuir, MD, MPH, and D. A. Henderson,
MD, MPH, in approximately 1959. Image from the Centers for Disease
Control and Prevention Public Health Image Library.
Service than in one of the armed services. In 1961, I was ap-
pointed chief of the Surveillance Section.
The explicit meaning of the term surveillance in a public
health setting was delineated by Alexander Langmuir in 1950
(4). The primary function of the newly established CDC was
to assist states in coping with infectious diseases. To dis-
charge this responsibility, he foresaw the need for “a sys-
tematic source of information regarding the communicable
disease problems of the nation” (5, p. 183). Langmuir pointed
out that until 1950, the term surveillance in public health was
used to indicate certain functions related to the early detec-
tion of individuals with diseases such as diphtheria, viral en-
cephalitis, anthrax, rabies, and smallpox so that they might be
expeditiously isolated and other preventive measures taken.
He asserted, however, that “[b]eginning in 1950 in the United
States the term surveillance [would be] applied to specific
diseases rather than to single individuals” (4, p. 13).
Surveillance, when applied to a disease, means the continued
watchfulness over the distribution and trends of incidence
through the systematic collection, consolidation and evaluation
of morbidity and mortality reports and other relevant data. In-
trinsic in the concept is the regular dissemination of the basic
data and interpretations to all who have contributed and to all oth-
ers who need to know. The concept, however, does not encompass
direct responsibility for control activities. Those traditionally have
been and still remain with the state and local health authorities.
(5, pp. 182–183)
Langmuir was inspired by the work of William Farr, who was
the superintendent of the Statistical Department of the Regis-
trar General’s Office for the United Kingdom for 40 years.
Farr believed that in recording and studying the trends of in-
fectious diseases, the natural laws of the behavior of diseases
would become evident and the causes of epidemics would
“admit to a great extent to remedy” (5, p. 182).
Langmuir’s new responsibilities were not unlike those of
Farr, with the exception that the recording of infectious dis-
ease data in the United States was not at the CDC but at the
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National Office of Vital Statistics in Washington, DC (6). In
1893, Congress authorized the weekly collection and publi-
cation of cases of notifiable diseases (essentially, those that re-
quired quarantine measures, such as smallpox, plague, cholera,
and yellow fever) from states and municipalities. By 1928, all
states and jurisdictions were reporting data on 29 specified dis-
eases. Between 1949 and 1960, compilation and weekly pub-
lication of these statistics were the responsibility of the National
Office of Vital Statistics.
In 1961, these responsibilities were transferred to the
CDC, which published the information in the Morbidity
and Mortality Weekly Report. It was customary at that time
for Langmuir and his senior staff (I was then chief of the Sur-
veillance Section) to review the weekly data before printing in
order to ascertain whether there were unexpected numbers of
cases in 1 or more states. If so, Langmuir would immediately
call the state epidemiologist or state health officer to ascertain
the reason and to offer emergency assistance from the CDC
if needed. Not infrequently, these calls resulted in a request
for assistance in field investigations and, ultimately, a better
epidemiologic understanding of disease behavior. These dem-
onstrations of interest in and use of what might otherwise have
been treated as routine reports facilitated working relationships
with state authorities and improved data quality and reporting.
To improve national efforts for infectious disease control,
Langmuir identified specific infectious diseases about which
additional information would be sought, special studies would
be encouraged or initiated, and periodic surveillance reports
would be issued (5). During the first 10 years, 3 diseases were
identified for surveillance initiatives: malaria (in 1950), polio-
myelitis (in 1953), and influenza (in 1957). Langmuir’s con-
cept of surveillance attracted significant international interest,
and it was selected as a topic for technical discussions at
the1968 World Health Assembly. In a special paper prepared
for these discussions, Langmuir succinctly summarized the
basic features that he considered to be essential for all surveil-
lance programs: 1) the systematic collection of pertinent data;
2) the orderly consolidation and evaluation of these data; and
3) the prompt dissemination of the results to those who need-
ed to know and to those who provided the information (7). A
fourth feature, the application of control measures, is a logical
complement of surveillance. It recognizes the importance of
surveillance in defining strategies and in gauging progress.
Langmuir emphasized in particular the importance of rapid
and widespread dissemination of surveillance information,
free of bureaucratic restraints, to all with an interest in the pro-
gram and to those with operational responsibilities.
Am J Epidemiol. 2016;183(5):381–386

EARLY SURVEILLANCE PROGRAMS
Malaria
Langmuir’s first effort to establish a surveillance program
focused on malaria. Malaria had long been endemic in the
United States, primarily throughout the Southeast, and it was
a concern for state and local authorities. World War II amplified
the problem as large numbers of troops were mobilized and
trained in greatly expanded military facilities, many of which
were located in the south. Between 90,000 and 150,000 cases
were reported annually. In 1942, the federal government initi-
ated a mosquito-control program called Malaria Control in War
Areas in proximity to training areas (8). After the war, in 1946,
the CDC was founded as the successor to Malaria Control in
War Areas. Its budget was modest, and more than 50% of its
staff of less than 400 people were engaged in mosquito abate-
ment and malaria habitat control (9).
As the name implies, the CDC’s responsibilities would
gradually diversify to include other infectious diseases. An
epidemiologist was required to oversee the support provided
to the states for all infectious disease problems. Langmuir
was recruited in 1949. Langmuir’s first efforts to establish a
surveillance program were focused on malaria (5); the return
of veterans from Korea who were infected with malaria had
generated a fear that malaria might spread more readily
throughout the civilian population.
Initially, reports of cases consisted largely of numbers of
individuals with suspected malaria that were reported irregu-
larly by physicians to local health departments. Studies soon
revealed that most of the case patients reported were persons
with no more than a febrile illness with or without other non-
specific symptoms; few cases were confirmed by detection of
malaria parasites in blood smears. Langmuir sought to have
more blood smears collected and to have patients identified at
least by name and residence. He insisted that, for a malaria
focus to be certified, there had to be 2 or more patients with
an epidemiologic relation to each other (5). His reasoning
was that a single case of malaria, however confirmed, might
be an importation and did not signify an endemic area.
Langmuir soon ascertained that there was no malaria in the
southern states and speculated that since 1945, there probably
had been no cases other than those in veterans who had re-
turned from malaria-endemic areas. Concern about malaria
abated rapidly, and at the time of my orientation training at
the CDC in July 1955, malaria was not even mentioned.
Poliomyelitis
The second surveillance program, which was for poliomy-
elitis, vividly and unexpectedly demonstrated the importance
of surveillance. In early April 1955, the results of an exten-
sive field trial of the new, inactivated poliomyelitis virus vac-
cine (i.e., the Salk vaccine) were announced. The vaccine was
pronounced efficacious and safe, and a full-scale national
vaccine program began. The only concerns of Langmuir and
the CDC staff were possible mistakes in diagnosis (i.e., the
possible misdiagnosis of polio-like disease caused by other
viruses) and vaccine failure due to improper handling of the
vaccine. No one anticipated the possibility that live poliovirus
might be present in the new vaccine (5).
Am J Epidemiol. 2016;183(5):381–386
The Development of Surveillance Systems 383
On April 25, 1955, a case of polio was reported from Chi-
cago, Illinois, and 5 more were reported the following day
from California. The interval from inoculation to first paral-
ysis was just 9 days, and the paralysis in each case affected the
limb that received the inoculation. Two days later and with
only 6 known cases, the Surgeon General requested manu-
facturers to recall all outstanding lots of the vaccine. At the
same time, the Polio Surveillance Program was established
at the CDC, with Neal Nathanson as the senior epidemiologist.
(Nathanson later became a professor of epidemiology at the
Johns Hopkins School of Hygiene and Public Health and was
a founder, with Philip Sartwell, of Epidemiologic Reviews.)
Health officers were instructed to report cases by telephone
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or telegraph. On May 1, 1955, the first CDC poliomyelitis sur-
veillance program report was produced and sent to an initial list
of 200 persons. Included in the list were all who had responsi-
bility for polio vaccine production and those in charge of vac-
cination programs. The reports were published daily and were
made available to scientists, the press, and the public (5).
There was fear and panic throughout the country.
Langmuir was summoned to Washington, DC, by the Sur-
geon General, who argued that making the information so
widely available and so promptly heightened national fears.
Langmuir insisted that, in fact, the open availability of infor-
mation for press and public alike provided confidence that in-
formation was being received promptly and was being acted
upon. He believed that this would be more reassuring than if
efforts were made to suppress or otherwise distort the magni-
tude of the problem. Continued publication was approved,
but questions about how much information should be pub-
lished and in what form were raised repeatedly. Langmuir
persisted in his belief that the best policy was that of openness
and of letting the information speak for itself.
The potential magnitude of the disaster was a major con-
cern. However, from the shape of the epidemic curve gener-
ated based on 42 cases and on data derived from experimental
animal studies, it was predicted in early May that fewer than
100 cases would occur among individuals who had been vac-
cinated. There were 79. Among family contacts, there were
105 cases. A detailed review of production protocols revealed
that a single manufacturer, Cutter Laboratories, was the only
producer with a vaccine that contained live poliovirus. By au-
tumn, it was possible to reassure the public and to resume
polio vaccination (5).
This episode vividly demonstrated the value of surveillance—
prompt reporting, analysis, and interpretation of information—as
well as of making the findings available to decision-makers,
consumers, producers, and the press. Without this program,
there might well have been loss of confidence in polio vacci-
nation and a long-term suspension of a major public health
intervention.
Influenza
By the spring of 1957, the polio vaccine crisis had sub-
stantially resolved. However, alarming notifications were re-
ceived in the United States about the occurrence of major
epidemics of influenza in China and then in Hong Kong
and the Middle East (10). A new strain of influenza was
suspected and confirmed. Virus samples were flown to the
384 Henderson
United States, and work began to develop a protective vac-
cine. By June, the first influenza outbreaks in the United
States were detected on naval bases and soon thereafter in
children’s camps and student conferences scattered across
the country. Could this be the beginning of an influenza pan-
demic comparable to the one in 1918? It was the first occa-
sion in which an early warning of a possible pandemic had
been given and the first instance in which a surveillance pro-
gram of some sort was contemplated.
The Surgeon General decided that a comprehensive national
program should be implemented. What specifically should be
incorporated into a surveillance program? The CDC was a
little-known agency, still in its infancy and housed in a down-
town office building, with only a handful of epidemiologic
staff. The CDC epidemiologists at that time consisted almost
entirely of Epidemic Intelligence Service professionals, primar-
ily physicians, who had chosen, as I had, to perform their na-
tional service in the Public Health Service. All had received 1
month’s training in epidemiology and biostatistics. With my 2
years of service, I was one of the more senior members.
A first initiative was to publish a weekly Influenza Surveil-
lance Report (as had been done with polio) and to seek infor-
mation about the progress and severity of the disease (11). There
was no system for reporting of cases or suspected cases, nor was
it apparent how such reports could be validly interpreted, given
the nonspecific symptoms of influenza. Innovation was neces-
sary, and several approaches were taken, including county-level
reporting, absenteeism reporting from industry, examination of
death reports, and investigation of outbreaks.
County reporting. Review of data during the early months
of the epidemic revealed that when outbreaks occurred, they
spread rapidly and were intense, with high absence rates in
schools and industry. Press coverage was frequent. Thus, in
late August 1957, with assistance from state health officers,
a system was established based on county experience. State
officials were asked to report outbreaks as they occurred and
to provide the date of the beginning of the outbreak, an esti-
mated attack rate, the number of deaths, and any other salient
information. Reports came from 1,927 of the country’s 3,068
counties, comprising more than 80% of the population (11).
Industrial absenteeism. At the time, a number of the
larger companies could provide absenteeism data but only
after delays of weeks to months. However, the Bell System,
which had 60,000 employees and offices throughout the
country, compiled information weekly and generously shared
it with the CDC (11).
Mortality data. Weekly reports of deaths by cause from
108 large cities were routinely reported at that time. For sur-
veillance purposes, cases coded as “pneumonia” or “influ-
enza” were tabulated separately and analyzed. Later studies
revealed that most records of deaths in that period were re-
ceived within 10 days after death (11).
Outbreak investigations. A surprisingly large number of
outbreaks in summer camps and in college dormitories
occurred in June and July of 1957 (11). Investigations of
these outbreaks, analyses of their characteristics, and write-ups
were expedited by Epidemic Intelligence Service staff and
published quickly in weekly Influenza Surveillance Reports.
Many of the studies followed similar formats, thus providing
valuable comparative data.
The temporal behavior of influenza was unexpected. The
October peak in incidence throughout the country was excep-
tionally early and reminiscent of the fatal 1918 pandemic.
However, the national mortality reports indicated nothing
more than the numbers of deaths customarily seen with influ-
enza epidemics. A second peak in influenza deaths in February,
with very few community-wide outbreaks, was puzzling. Ex-
planations were sought, but no answers were forthcoming (11).
Langmuir’s second surveillance effort did little to abate the
influenza epidemic, although hospitals and public health
units were better prepared to deal with the epidemic as it de-
veloped. Vaccine production began, but too few doses were
produced too late to be of value. However, the surveillance
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effort demonstrated that with national leadership provided
by a small CDC staff, impressive quantities of pertinent
and timely information could be compiled, analyzed, and
widely distributed. Academic centers, industry, and health
agencies at the national, state, and local levels proved to be
interested and cooperative participants. An influenza surveil-
lance program has continued ever since.
THE GLOBAL SMALLPOX ERADICATION PROGRAM
Origin of the program
In 1961, surveillance took on a new meaning for me when,
in June, I was appointed chief of the Surveillance Section at
the CDC. Our interests at that time were initially in the sur-
veillance of viral diseases, notably polio, influenza, measles,
and hepatitis. It was at this time that smallpox intruded on the
agenda. Importations of smallpox into Europe began to occur
coincident with increasing air travel between Asia and Europe.
We anticipated that the disease would be imported into the
United States. We therefore focused our research on methods
to speed smallpox vaccination using jet injectors and on the
possibility of simultaneous administration of the smallpox vac-
cine with other vaccines.
In 1965, the CDC was presented with an unexpected re-
quest from the US Agency for International Development
(USAID) to provide supervisory staff for a 4-year mass vac-
cination campaign against measles in western Africa. USAID
would cover all costs for the campaign. The Agency’s as-
sumption was that in the longer term, the countries would
sustain the programs themselves using national funds (2).
The plan seemed unrealistic. The measles vaccine cost
$1.50 per dose, which was an unaffordable expense for Afri-
can governments. Abandoning US support for the program at
the end of 4 years of operations seemed politically problem-
atic and ethically unconscionable. We sought an alternative
that would provide for measles vaccine to be given and that
at the same time would be constructive for a longer-term pub-
lic health agenda. We proposed a plan to USAID that called
for mass vaccination using jet injectors to administer both
smallpox and measles vaccines. The addition of the smallpox
vaccine was important of itself. Its cost was only $0.02 per
dose, and it prevented a disease even more serious than mea-
sles. When USAID support for measles vaccine ceased,
countries could continue the smallpox vaccination program.
We proposed that the program extend throughout a geograph-
ically contiguous block of 18 West African countries (2).
Am J Epidemiol. 2016;183(5):381–386

The program was far more ambitious and costly than
USAID had envisioned. However, we hoped to reach some
sort of modest compromise. To our surprise, USAID approved
the program in its entirety in November 1965. The CDC had
never been given an international responsibility such as this.
As we learned, the President wanted to announce a new US
assistance program in conjunction with World Health Day,
an annual WHO celebration. Our proposal was selected. Field
operations were to commence in January 1967.
As the program in West Africa took shape, the World
Health Assembly debated the feasibility of the WHO em-
barking on a 10-year global smallpox eradication program
in May 1966 (2). National opinions were divided. The 40
or so countries in which smallpox was endemic were highly
desirous of such a program; others believed it was unrealistic
to try to eradicate any disease. The Director General was
skeptical and concerned. The extensive and costly 12-year-
old WHO malaria eradication program was faltering. Failure
of a second eradication program could seriously affect the
credibility of the WHO and international public health. How-
ever, by a margin of 2 votes, the World Health Assembly ap-
proved the smallpox eradication initiative. The affirmative
votes of the West African countries proved decisive. I was
asked to assume the position of director of the Global Small-
pox Eradication campaign, which began in January 1967.
A smallpox surveillance system
From the outset, we gave priority to the development of sur-
veillance. It was astonishing to discover how little was known
about the current extent of smallpox. By international agree-
ment, all cases of the 4 so-called quarantinable diseases were
required to be reported promptly to the WHO. However, re-
porting was so poor that a 1964 WHO Expert Committee on
Smallpox stated that nothing could be said about numbers of
cases of smallpox (12). At that time, most national health pro-
grams reported smallpox control activities in terms of numbers
vaccinated. How many vaccinations were successful was never
stated and seldom measured. As we were to discover, less than
10% of the vaccine then in use met international standards.
From the beginning of the program, we were firmly of the
belief that an effective surveillance system was essential to the
design, shaping, and monitoring of an international program.
In each country, and especially in the 31 countries in which
smallpox remained endemic, it was essential to build broad
public health support for and active participation in a smallpox
surveillance system. Weekly case reports were needed from
hospitals, clinics, and dispensaries. We recommended that
small teams be formed to investigate each outbreak, to vacci-
nate immediate contacts of case patients, and to record all cases
of disease that they discovered (3). Central surveillance units
were necessary to evaluate the data and produce regular reports
for the WHO and for wide distribution to staff, technical and
political leadership, and the press.
Within the first 3 years of the program, dramatic results in
smallpox control began to be reported from West Africa,
Madras State in India, and Brazil. Analysis of surveillance
reports demonstrated that smallpox spread comparatively
slowly. In some areas, it could be stopped altogether by limited
containment and vaccination. Analysis also indicated that
Am J Epidemiol. 2016;183(5):381–386
The Development of Surveillance Systems 385
smallpox vaccine protection extended for years and that
repeated revaccinations were unnecessary.
Surveillance reports
In keeping with the principle that feedback via regular re-
ports enhanced data quality as well as effort and interest in the
program, we decided to publish an international surveillance
report every 2 to 3 weeks that provided current information
about cases, a discussion of epidemiologic findings, and pro-
gram strategies (2). By November 1967, we distributed the
first surveillance report to 250 WHO smallpox staff and na-
tional program directors.
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One month later, I was informed that the Director General
forbade any new WHO publications pending an 18-month re-
view of all publications of the organization. I met with the
Director General to explain surveillance principles and the
importance of regular publication. I informed him that it
would not be possible for me to continue service with the
WHO without a surveillance publication. Within a week, I
was informed that smallpox surveillance information could
be published in WHO’s Weekly Epidemiological Record.
This reached some 5,000 health officials and others world-
wide by surface mail. The smallpox surveillance section was
printed separately and distributed by air mail to 150–200
WHO and national program staff. Between 1968 and 1980,
151 Smallpox Surveillance Reports were printed and distrib-
uted. During the last 5 years of the program, an additional,
often more candid, publication called Target Zero Progress
Report was distributed to program staff.
Eradication of the world’s most feared and destructive dis-
ease was achieved in just over 10 years, falling from 10 mil-
lion cases and 2 million deaths in 1967 to 0 in 1977. It is the
first and, so far, only human disease to have been eradicated.
There were many key factors: dedicated, innovative staff mem-
bers who did not accept the view of most experts that eradica-
tion was impossible, the invention of the bifurcated needle for
vaccination, the production of a heat-stable smallpox vaccine,
and epidemiologic studies that changed strategies and under-
standing. All were bought together by national and interna-
tional staff members who advocated, contributed, innovated,
and sacrificed for both family and career. The core catalytic
factor was surveillance.
ACKNOWLEDGMENTS
Author affiliation: Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland (D. A.
Henderson).
I thank Dr. Leigh Henderson for her contributions to this
paper as both a historian–epidemiologist and an editor.
Conflict of interest: none declared.
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