The Concept of

Epidemiologic
Surveillance
Ari Udijono
Epidemiology & Tropical Diseases Department
Faculty of Public Health - Diponegoro University
Semarang Indonesia

Presented in the Epidemiologic Surveillance Course Central Java Province; Wonosobo, August 5, 2019
Subjects
 Epidemiologic concept
 Understanding epidemiologic surveillance
 Pathogenesis in public health problems
 Risk factors of public health events
 Data analysis and interpretation
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
health problems

(WHO)
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
‘Study’ includes surveillance, observation,
application of this study to control of
hypothesis testing, analytic research, and
health problems
experiments

(WHO)
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
‘Distribution’ refers to analysis by time, place,
application of this study to control
and classes of persons affected
of
health problems

(WHO)
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
‘Determinants’ are all the physical, biological,
health problems
social, cultural, and behavioral factors that
influence health
(WHO)
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
‘Health-related states and
health problemsevents’ include
diseases, cause of death, behavior such as use
of tobacco, reactions to preventive regimens,
(WHO)
provision and use of health services
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
health problems
‘Specified populations’ are those with
identifiable characteristics such as
precisely define numbers (WHO)
 Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
health problems

‘Application to control of health problems’

(WHO)
makes explicit the aim of epidemiology – to
promote, protect and restore health
 Epidemiology
 Epidemic + Logos
 Communicable diseases
 Diseases (communicable + non-communicable diseases)
 Health Problems
 Omran: Epi (around) + Demos (people) + Logos
 Surveillance
the ongoing systematic collection, collation,
analysis and interpretation of data; and
the dissemination of information
to those who need to know
in order that action may be taken
(WHO, 1996)
 Surveillance
a continuous and systematic process of collection,
analysis, interpretation, and dissemination of
descriptive information for monitoring health
problems (Rothmans, 1998)
 Surveillance
the ongoing and systematic collection, analysis and
interpretation of outcome-specific 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 of the
surveillance chain is the application of these data to the
control an prevention of human disease and injury
(Thacker, 1996)
 Public Health
Surveillance
the ongoing systematic collection, analysis, and
interpretation of outcome-specific data for use in
the planning, implementation, and evaluation of
public health practice (Teutsch, 2000)
 The Uses of
Surveillance
 Quantitative estimates of the magnitude of a health
problems
 Portrayal of the natural history of disease
 Detection of epidemics
 Documentation of the distribution and spread of a health
event
 Facilitating epidemiologic and laboratory research
 The Uses of
Surveillance
 Testing of hypotheses
 Evaluation of control and prevention measures
 Monitoring of changes in infectious agents
 Monitoring of isolation activities
 Detection of changes in health practice
 Planning
Pathogenesis
 The pathogenesis of a disease is the biological mechanism progress of
disease showing its morphological features or that leads to the
diseased state.
 The term can also describe the origin and development of the
disease, and whether it is acute, chronic, or recurrent.
 Most diseases are caused by multiple processes.
 The pathogenic mechanisms of a disease (or condition) are set in
motion by the underlying causes, which if controlled would allow the
disease to be prevented.
Pathogenesis
 Often, a potential cause is identified by epidemiological observations
before a pathological link can be drawn between the cause and the
disease.
 The pathological perspective can be directly integrated into an
epidemiological approach in the interdisciplinary field of molecular
pathological epidemiology.
 Molecular pathological epidemiology can help to assess pathogenesis and
causality by means of linking a potential risk factor to molecular pathologic
signatures of a disease.
 Thus, the molecular pathological epidemiology paradigm can advance the
area of causal inference.
Natural History of
Disease
 The progress of a disease process in an individual over time, in the
absence of intervention.
 The process begins with exposures to or accumulation of factors
capable of causing diseases.
 Without medical intevention, the process end with recovery, disability
or death.
Recovery
Exposure Host Disease Disability
Death
Natural History of
Disease
 Established by cohort studies.
 Understanding natural history of disease is largely based on other
epidemiological studies, and undertaken in different population
settings.
 What the physician sees in the hospital is just an ‘episode’ in the
natural history of disease.
 The epidemiologist setting is in a unique positionto fill the gaps in the
knowledge about the natural history of disease.
Natural History of
Disease
 The natural history of disease and spectrum of disease presents
challenges to the clinician and to the public health worker.
 Cases of illness diagnosed by clinicians in the community often
represent only the ‘tip of the iceberg’.
 Many additional cases may be too early to diagnose or may remain
asymptomatic.
 For the public health worker, the challenge is that persons with
undiagnosed infections may nevertheless be able to transmit them to
others.
Determinants of health
 Many factors combine together to affect the health of individuals and
communities.
 Whether people are healthy or not, is determined by their
circumstances and environment.
 To a large extent, factors such as where we live, the state of our
environment, genetics, our income and education level, and our
relationships with friends and family all have considerable impacts on
health, whereas the more commonly considered factors such as
access and use of health care services often have less of an impact.
Determinants of health
 The determinants of health include:
 the social and economic environment,
 the physical environment, and
 the person’s individual characteristics and behaviours.
 The context of people’s lives determine their health, and so blaming
individuals for having poor health or crediting them for good health is
inappropriate.
 Individuals are unlikely to be able to directly control many of the
determinants of health.
Risk Factors
 A risk factor is any attribute, characteristic or exposure of an
individual that increases the likelihood of developing a disease or
injury.
 Some examples of the more important risk factors are underweight,
unsafe sex, high blood pressure, tobacco and alcohol consumption,
and unsafe water, sanitation and hygiene.
 Something that increases a person's chances of developing a disease.
Risk Factors
 An aspect of personal behavior or lifestyle, an environmental exposure, or
an inborn or inherited characteristic that, on the basis of scientific
evidence, is known to be associated with meaningful health-related
condition(s). In the twentieth century multiple cause era, a synonymous
with determinant acting at the individual level.
 An attribute or exposure that is associated with an increased probability of
a specified outcome, such as the occurrence of a disease. Not necessarily a
causal factor: it may be a risk marker.
 A determinant that can be modified by intervention, thereby reducing the
probability of occurrence of disease or other outcomes. It may be referred
to as a modifiable risk factor, and logically must be a cause of the disease.
Risk Factor
• The term risk factor became popular after its frequent use by T. R.
Dawber and others in papers from the Framingham study.
• The pursuit of risk factors has motivated the search for causes of
chronic disease over the past half-century.
• Ambiguities in risk and in risk-related concepts, uncertainties inherent
to the concept, and different legitimate meanings across cultures
(even if within the same society) must be kept in mind in order to
prevent medicalization of life and iatrogenesis.
Causality
 The relating of causes to the effects they produce. The property of
being causal. The presence of cause. Ideas about the nature of the
relations of cause and effect. The potential for changing an outcome
(the effect) by changing an antecedent (the cause).
 Most of clinical, epidemiological, and public health research concerns
causality.
 In the health and life sciences, causality is often established by
integration of biological, clinical, epidemiological, and social evidence,
as appropriate to the hypothesis at stake.
Causality
 Several types of causes can be distinguished.
 A cause is termed “necessary” when it must always precede an effect. This
effect need not be the sole result of the one cause.
 A cause is termed “sufficient” when it inevitably initiates or produces an
effect.
 The following factors have been differentiated, although they are not
mutually exclusive:
 Predisposing factors
 Enabling factors
 Precipitating factors
 Reinforcing factors
Hill’s Criteria of
Causality
 Strength (effect size): A small association does not mean that there is
not a causal effect, though the larger the association, the more likely
that it is causal.
 Consistency (reproducibility): Consistent findings observed by
different persons in different places with different samples
strengthens the likelihood of an effect.
 Specificity: Causation is likely if there is a very specific population at a
specific site and disease with no other likely explanation. The more
specific an association between a factor and an effect is, the bigger
the probability of a causal relationship.
Hill’s Criteria of
Causality
 Temporality: The effect has to occur after the cause (and if there is an
expected delay between the cause and expected effect, then the
effect must occur after that delay).
 Biological gradient: Greater exposure should generally lead to greater
incidence of the effect. However, in some cases, the mere presence of
the factor can trigger the effect. In other cases, an inverse proportion
is observed: greater exposure leads to lower incidence.
 Biological Plausibility: refers to the proposal of a causal association –
a relationship between a putative caused and an outcome – that is
consistent with existing biological and medical knowledge.
Hill’s Criteria of
Causality
 Coherence: Coherence between epidemiological and laboratory
findings increases the likelihood of an effect. However, Hill noted that
"... lack of such [laboratory] evidence cannot nullify the
epidemiological effect on associations".
 Experiment: "Occasionally it is possible to appeal to experimental
evidence".
 Analogy: The use of analogies or similarities between the observed
association and any other associations.
 Some authors consider also, the Reversibility: If the cause is deleted
then the effect should disappear as well.
 Surveillance
Health Services System Public Health Authority
Reporting
Data Information

Evaluation Analysis &

Interpretation

Feedback
Actions Decisions

33
 Data Analysis &
Interpretation
 Data Analysis: is the process of evaluating data using analytical and
statistical tools to discover useful information and aid in business
decision making. There are a several data analysis methods including
data mining, text analytics, business intelligence and data
visualization.
 Person, Place and Time (Epidemiologic Determinants).
 Technique of analysis: Descriptive Epidemiology.
 Present as table, graph or other methods to describe the data.

34
 Data Analysis &
Interpretation
 Interpretation: is the process of making sense out of a collection of
data that has been processed.
 Data interpretation refers to the implementation of processes through
which data is reviewed for the purpose of arriving at an informed
conclusion.
 The interpretation of data assigns a meaning to the information
analyzed and determines its signification and implications.

35
 Data Analysis &
Interpretation
 The importance of data interpretation is evident and this is why it needs to
be done properly.
 Data is very likely to arrive from multiple sources and has a tendency to
enter the analysis process with haphazard ordering.
 Data analysis tends to be extremely subjective. That is to say, the nature
and goal of interpretation will vary from business to business, likely
correlating to the type of data being analyzed.
 While there are several different types of processes that are implemented
based on individual data nature, the two broadest and most common
categories are “quantitative analysis” and “qualitative analysis”.

36
 f D ata
ti o n o
r preta
& Inte
a l ys i s
An
 Decision Making
 Step 1: Define Your Questions
 Step 2: Set Clear Measurement Priorities
 Decide what to measure
 Decide how to measure it
 Step 3: Collect Data
 Step 4: Analyze Data
 Step 5: Interpret Results

38
 Decision Making
 Step 1: Define Your Questions
 Step 2: Set Clear Measurement Priorities
 Decide what to measure
 Decide how to measure it
 Step 3: Collect Data
 Step 4: Analyze Data
 Step 5: Interpret Results

39
 Public Health
Dissemination
 the action or fact of spreading something, especially public health
information, widely.
 "the dissemination of public health information“.
 Dissemination takes on the theory of the traditional view of
communication, which involves a sender and receiver.
 The traditional communication view point is broken down into a
sender sending information, and receiver collecting the information
processing it and sending information back.

40
 Public Health
Dissemination
 With dissemination, only half of this communication model theory is
applied.
 The information is sent out and received, but no reply is given.
 An example of this transmission of information is in fields of
advertising, public announcements and speeches.
 The message carrier sends out information, not to one individual, but
many in a broadcasting system.

41
 Public Health
Dissemination
 In a scientific context, dissemination is defined as making projects
results available to the scientific community, policy makers and
industry – using scientific language prioritizing accuracy.
 In terms of content, it covers the results of the research project,
happens only when results are available and targets a specialist
audience in order to enable take-up and use of results.

42
Latihan-latihan..
 Deteksi outbreaks dysentery dengan memonitor
incidence kasus diare berdarah
Kasus diare berdarah di kab.X menurut bulan, January 1994- April 1995

1994 1995
Monitor kemajuan eradikasi polio memonitor incidence
poliomyelitis dimana diketemukan virus liar pada anak umur
dibawah 14 tahun
Kasus poliomyelitis dimana poliovirus liar diisolasi
dari anak diKab. X, 1980-1996
Monitor incidence malaria secara lab dan
proporsi P. falciparum

Kasus malaria di suatu wilayah, 1992-1996

Mengukur incidence of AIDS untuk prediksi trend mendatang
dan perencanaan pelayanan kesehatan

Cases of AIDS in a city district, 1990-2004

Monitor kemampuan program TB untuk menjamin kelengkapan
pengobatan dan kesembuhan

Treatment completion and cure in TB cases, 1994-1997

 Urutan kejadian pada deteksi dan konfirmasi
KLB (I)
Primary 1st case Report Samples Lab Response
Case at HC to DMO taken result begins

CASES
Opportunity
for control

49
DAY
 Urutan kejadian pada deteksi dan konfirmasi
KLB (II)
Response
PRIM HC REP SAMP RES begins

Potential
CASES cases prevented

50
DAY