Principles of Surveillance

Lazareto de Mahón, Menorca, Spain

9th October 2006

EPIET 2004; Denise Werker

EPIET 2005; Suzanne Cotter
EPIET 2006; Susan Hahné
Content
 aim of lecture
 context, definitions and history of surveillance
 the process
 aims of surveillance
 criteria for undertaking surveillance
 surveillance versus research
 steps in setting up surveillance
 challenges & opportunities
 summary
Aim
After the lecture, you should be able to…
Define:
 surveillance
 its three main components

Describe:
 the contexts / historical perspective of surveillance
 possible aims
 criteria for undertaking surveillance
 the difference between surveillance and research
 the different steps in setting up surveillance
 some challenges and opportunities
Context (1)
Surveillance in EPIET Introductory Course
Presentations
 Principles of surveillance
Problem-based exercises
 Secular trends
 Surveillance
– set up surveillance
– analytic tools for surveillance
– evaluation of surveillance systems
Context (2)
Intervention Epidemiology
 Surveillance
 Outbreak investigation
 Applied epidemiological research
Context (3)

Control of Communicable Diseases: Tools

 isolation
 treatment
 disinfection & barriers
 quarantine & surveillance
 vaccination
 prophylaxis
Context (3)

Control of Communicable Diseases: Tools

 isolation
 treatment
 disinfection & barriers
 quarantine & surveillance
 vaccination
 prophylaxis
‘Close observation of individuals
suspected of incubating serious infectious diseases
in order to detect initial symptoms of disease
in time to institute treatment and isolation’
 Definition - dictionary

Surveillance
n. Close observation, especially of a suspected
spy or criminal
ORIGIN C19: from Fr., from sur- 'over' + veiller
'watch'
  Source: The Concise Oxford Dictionary. Ed. Pearsall J. Oxford University Press, 2001.
 Definition – epidemiology (1)

Surveillance

“The continuing scrutiny of

all aspects of occurrence and spread of disease
that are pertinent to effective control”

Source: Last JM. A Dictionary of Epidemiology (Second Edition). Oxford University Press 1988, New York.

 
Definition – epidemiology (2)

Surveillance
“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
together with the timely and regular dissemination
to those who need to know”
Source: Alexander Langmuir (1910 – 1993)
Historical perspective (1)
First use for Public Health Action
William Farr (1807 – 1883)
 Superintendent, statistical department, General
Register Office, England and Wales
 Collected, analysed, interpreted vital statistics
 Plotted rise and fall of epidemics of infectious
diseases, identifying associations
 Disseminated information in weekly, quarterly,
and annual reports, medical journals, public
press
Historical perspective (2)
Recognition by World Health Organization
21st World Health Assembly (1968)
 Systematic collection of pertinent data
 Orderly consolidation and evaluation of these
data
 Prompt dissemination of the results to those who
need to know

"Information for action"

Surveillance is a cyclical process

Health Care System Public Health Authority

Reporting
Event Data
Capture

Real world! … Analysis &

expected Interpretation
changes

Dissemination
Intervention Information
Aims of Surveillance (1)
Actions: examples
 manage contacts of a case
 detect outbreaks
 early warning
 design/change vaccination policy
 design policy re antimicrobial resistance
 evaluate interventions to improve them
 certify elimination / eradication
Aims of Surveillance (2)
Public Health aims
 Assess public health status (monitor trends,
detect outbreaks)
- prevent and control disease
 Define public health priorities
- plan considering impact of hazard, exposure, disease
 Evaluate public health programmes
- make decisions regarding interventions
 Stimulate or inform research
- generate hypotheses, inform methodologie
Criteria for undertaking surveillance
Public Health importance / rationale
 burden of disease (incidence / prevalence)
 severity, mortality
 epidemic potential, threat
 costs, socio-economic impact
 preventability / opportunities for control
 public concern and news-worthiness
Feasibility
 costs
 availability of data
Surveillance versus Research
Surveillance
 Applies existing knowledge to guide health
authorities in the use of known control measures
 Directly relevant to monitoring and control needs
Research
 Pursues new knowledge from which better
control measures will result
 Systematic investigation, testing and evaluation,
designed to develop or contribute to knowledge
Steps in setting up surveillance (1)
1. Understand the problem
2. Identify opportunities for prevention &
control
- interventions
- target audience
3. Set objectives
4. Specify requirements to meet objectives
5. Design
- case definitions & indicators
- data needed
- data sources
- data transfer
Steps in setting up surveillance (2)
5. Translate information into action
- analyse
- interpret
- disseminate
6. Evaluate surveillance system
1. Understand the problem

Transmission Environment
Exposure
Vector
Direct

Source of
infection

Infection

Disease

Death
Recovery Reservoir
Disability
 2. Identify opportunities for prevention & control

Transmission Environment
Exposure
Vector

6. Prevent transmission
Direct
1. Vaccination e.g. universal precautions
Source
infection

Infection 4. Isolation/ treatment

5. Ecological Management
2. Prophylaxis
Disease
3. Treatment Reservoir
Recovery
Death
Disability
2. Identify opportunities for prevention & control
Target audiences
 Public Health professionals
 Government / Politicians
 Clinicians / Microbiologists / Control of
Infection staff
 Environmental Health professionals
 Health service managers
 Health educators / teachers
 Public
3. Set objectives
SMART
 Specific
 Measurable
 Acceptable and Action oriented
 Realistic
 Time related
3. Set objectives - examples

Vague...
 To estimate the prevalence of hepatitis C
 To detect outbreaks of measles

Specific, measurable, action-oriented & timed

 To assess the prevalence of hepatitis C in
France in order to allow planning of specific
health care needs for the coming 20 years
 To detect early time and place clustering of
measles cases in order to ensure timely control
of outbreaks
4. Requirements of the system

Keep it as simple as possible!!

 Timeliness
 Sensitivity
 Specificity
 Completeness of information
 Representativeness
 Acceptability
5. Design – case definitions

Report

Lab confirmed

Clinical specimen

Seek medical attention

Symptoms

Infected

Exposed
5. Design – examples of data needed

 Numerators
- number of cases
- number of resistant strains

 Denominators
- population under surveillance
- life births (CRS)
- bacterial isolates (AMR)
5. Design – data sources (1)

 Health service
– notifications
– laboratories
– disease registries
– community services
– emergency services
– screening programmes (antenatal, blood
donors)
– pharmacy / over the counter drugs
– vaccination programmes
5. Design – data sources (2)

 Veterinary
– animals (domestic, wild)
– food
 Environment
– water
– food
– air
 Population statistics
– deaths
– denominators
5. Design – data sources (3)

Issues
 cost
 representativeness
 comparability
 confidentiality
 acceptability
 data quality
 timeliness
 commercial sensitivity
5. Design – data transfer
 Existing infrastructure
 Methods
– web-based
– telephone
 Frequency
 Zero reporting
5. Design – addition design issues

 Sampling vs. comprehensive

 Aggregated vs. individual data
 Active vs. passive
 Statutory vs. voluntary
 Confidential vs. anonymous
 Security
6. Information into Action (1)

 Analysis
– descriptive (time, place, person)
– time series
– outbreak detection
– molecular epidemiology
– geographical information
systems (GIS)

 Interpretation
– system and data characteristics and changes
– chance, bias, truth
6. Information into Action (2)

 Dissemination of information
– develop outputs in consultation with users
– appropriate level of detail for action
– regular review of usefulness
– avoid information overload
7. Evaluation of surveillance system

Did the system do what it set out to do?

Surveillance – the challenges
 Surveillance or research needed?
 Reliability
– crude and inaccurate
– incomplete
– accurate denominators
 Sustainability
– victim of success of control
 New threats
– emerging infections
– bioterrorism
 Timeliness
 Human Rights
– data protection
Surveillance – the opportunities
 Near patient testing
 Less invasive diagnostics (oral fluid, urine)
 New molecular typing methods
 Electronic patient records
 ‘New’ data sources
 Behavioural surveillance
 Syndromic surveillance
 On-line, web-based systems
– data entry
– dissemination of information
 New analysis methods
– GIS
– bio-informatics
– modelling
Summary
 Context
– communicable disease control
– epidemiology
 Definition
– ‘information for action’
 General process
– capture
– analysis
– dissemination
 Aims
 Criteria to set up surveillance system
– public health importance
– feasibility
– difference between surveillance and research
 Different steps
 Challenges and opportunities
Thank you!