08-Principles of Surveillance

Principles
of Disease Surveillance
EPIET, 2003
Guénaël Rodier, Director, Communicable Disease Surveillance and Response, WHO, Geneva
WHO Communicable Diseases Surveillance & Response

Disease Surveillance
Epidemiology and laboratory to the rescue!

Surveillance: “data for action”
Surveillance is 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
Rationale for Disease Surveillance
• Public health importance of disease ?
• Can public health action be taken ?
• Are relevant data easily available ?
• Is it worth the effort (money,

human resources)?

What are the
objectives of surveillance ?

Objectives of surveillance
• Epidemic (outbreak) detection

• Monitoring trends in endemic disease
• Evaluating an intervention
• Monitor progress towards a control objective
• Monitor programme performance
• Epidemic (Outbreak) prediction
• Estimate future disease impact

Surveillance: Objectives/Targets
Specific
Measurable
Action oriented
Realistic
Timely

Objective: To detect outbreaks of dysentery by
monitoring the incidence of cases of
acute bloody diarrhoea
Cases of acute bloody diarrhoea in a rural district by month,

January 1994- April 1995
120
Cases
100
80
60
40
20
0
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Objective : To monitor the incidence and case fatality rate of
acute respiratory infection (ARI) in children under
5 years
Cases and deaths from ARI in a
rural district, 1992-1996
2500
Deaths
2000 Cases
1500
1000
500
0
1992 1993 1994 1995 1996

Objective: To monitor progress towards polio eradication
by monitoring the incidence of poliomyelitis
where wild poliovirus is isolated in children
under 14 years
Cases of poliomyelitis where wild poliovirus was isolated
in children in a rural district, 1980-1996
250
NID
Cases
200
150
NID
100
50
0
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96

Objective: To monitor the incidence of laboratory confirmed
malaria and proportion due to P. falciparum
Cases of malaria in a region, 1992-1996
600
500
Others
400
Faciparum
300
200
100
0
1992 1993 1994 1995 1996

Objective: To measure the incidence of AIDS to predict
future trends and facilitate health service
planning
Cases of AIDS in a city district, 1990-2004
700
600
500
400
300
200
100
0
90 91 92 93 94 95 96 97 98 99 0 1 2 3 4

Objective: To monitor the ability of a TB programme to
ensure treatment completion and cure
Treatment completion and cure in TB cases, 1994-
1997
1600
1400
1200
1000 Cases
800 Completion
600 Cure
400
200
0
1994 1995 1996 1997

Objective : To monitor the course of an outbreak.
Probable cases of SARS by date of onset, Viet Nam (n=61*)

1 February - 7 April 2003
10
7
number of cases
0
1-Feb-03 8-Feb-03 15-Feb-03 22-Feb-03 1-Mar-03 8-Mar-03 15-Mar-03 22-Mar-03 29-Mar-03 5-Apr-03
date of onset

HIV/AIDS Key epidemiological questions
• What are the levels and trends in HIV infection?

• Who is getting infected?
• Who is at risk for or vulnerable to HIV infection?
• What is the impact of the epidemic?
• What are the resource needs?
• Is the response effective?
WHO internal meeting,
2 October 2001

Surveillance: General principle
Health Care System Public Health Authority
Reporting
Event Data
Real world! … Analysis &

expected Interpretation
changes
Decision
Intervention Information
(Feedback)

Reporting
Data
HEALTH EVENT
• Disease
• Syndrome (e.g., AFP, jaundice, VHF)
• Public health issue (e.g., AMR)
• Environment (e.g., animal vector, water)
Information

DATA SOURCE (1)

Data
• Clinic
• Laboratory
• Other
• Vital statistics (e.g. death certificates)


DATA SOURCE (2)
• Entire population Data
• Selected age-group, gender

• Selected exposure
• Other criteria


DATA SOURCE (3)
• Public sector Data
• Private sector, NGOs

• Selected sites (sentinel approach)
• Selected period of time

CASE DEFINITION (1)

Data
• Status (age, gender, exposure etc.)
• Clinical / laboratory / epidemiology
• Different levels (e.g. suspected,
probable, confirmed)

CASE DEFINITION (2)

Data
• Clear and simple
• Stable
• Field tested

t ed
te s
ld
f ie
ble, on!
st a initi
ple, d ef
s im ase
A c

Surveillance: Laboratory-based
“you see what Report surveillance
you look at”
Pos. specimen
Clinical specimen
Clinically-based
Seek medical attention surveillance
Symptoms Community-based surveillance
Infected Serological survey
Exposed

Reporting
Event frequency Data
• immediate
• weekly
• monthly ...
• zero reporting?

Reporting
Event methods Data
• Paper
• Telephone, Fax
• E-mail
• Web-based system

Surveillance: Data flow
Peripheral level Clinical
(suspected)
+ Supportive
Intermediate level
laboratory
data +
epidemiological
link (probable)
Diagnostic
Central level Ministry
of Health Laboratory
(confirmed)
Regional reference
Regional/International level laboratory
WHO
Event Data Analysis

• Data characteristics
• Data validation
• Descriptive analysis
• Hypothesis generation
Intervention

Event Data characteristics

• Various sources of
notifications
• Various levels of quality
• Continuous data collection
subject to change
Intervention

Event Data validation

• Missing values
• Bias
• Duplication
Intervention

Event Descriptive analysis

• Time
• Place
• Persons
Intervention

Event Hypothesis generation

• related to time
• related to place
• related to persons
Intervention

Event Data
Information use
• Control
• Feedback Information
• Policy
Event Data
Control
• Rapid response
• Case management
• Prevention Information
(e.g. immunization)

Event Data
Feedback
• Epidemiological bulletin
• Reports Information
• Website, others
Event Data
Policy
• Policy change
• Prediction, planning
• Epidemic preparedness Information

Surveillance: Functions
Core functions
• Detection
• Reporting
• Investigation & confirmation
• Analysis & interpretation
• Action / response
Support functions
• Training
• Supervision
• Resources
• Standards / guidelines
Public Health Surveillance
Different Objectives, Different Data, Different Methods
Epidemic Intelligence Health Status Monitoring

Early warning Health indicators
information
Epidemic Health
response Policy
Control Resource
activities allocation
Programme Administrative
Indicators data
Programme Monitoring Health System Monitoring

Surveillance: New Approaches
“Integrated” approach (co-ordination, synergy, between

surveillance activities)
“Syndromic” approach (avoid laboratory delay, report
what you see, avoid stigma, fill surveillance gaps, stable
definition)
e.g. AFP instead of polio, urethral discharge instead of gonorrhoea
“Internet-based” surveillance (national or international

networks; Web reporting; Web as a source of
data/information)
Geographic information systems (GIS) (multisectoral,
multidisease, remote sensing data etc.)

Integrated Surveillance approach
Disease specific: CDC Guidelines

(MMWR, May 1988, 37, S5) Integrated approach:
WHO Protocol, 1997-98
Reporting
Health Care Public Health
Event Data
SystemReporting Authorities
Event Data
Reporting
Event Data
changes
changes Real world! … Analysis &
Decision
Intervention changes Information
(Feedback) Decision
(Feedback) Decision
(Feedback)
HIV/AIDS
Malaria
Other ..

The Internet is an increasing source
of outbreak-related information
• MOH web sites (National

institutes, public health
laboratories)
• media wires news (AFP,
Reuters, BBC etc.)
• electronic discussion groups
(ProMed, PACNET, etc.)
• NGO web sites
• UN web sites (UNHCR,
UNICEF)
• etc.

Zaire ‘95
Molecular epidemiology: Zaire ‘76
Ebola virus phylogenetic tree
Ivory Coast ‘94
Sudan ‘79
Sudan ‘76
Reston ‘92
Reston ‘92
Reston ‘89
Reston ‘96
Ebola, Gulu, Uganda, 2000-2001

Marburg ‘87
Marburg ‘75
Marburg ‘80
Marburg ‘67

Public health mapping

Surveillance: Basic Ingredients
A good network of motivated people
Clear case definition and reporting mechanism
Efficient communication system
Basic but sound epidemiology
Laboratory support
Good feedback and rapid response

Surveillance of Communicable Diseases
Laboratory + Field Epidemiology + Communication

CDs Surveillance networks in Asia
WPRO-SEARO
Regional
Networks
APEC
SEAMIC
Mekong Pacific Public Health

Basin SEANET
Surveillance Network
Disease (PPHSN)
Surveillance
(MBDS) ASEAN
EIDIOR

Communicable Disease Surveillance
Build credibility first!
Country
Infrastructure
Priority 3 Diseases
Priority 2 Diseases
Alert and
Response Priority 1 Diseases
Capacity
Weeks-months years

Many other outbreak responses directly handled by WHO ROs

Thank you
http://www.who.int
outbreak@who.int

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Principles

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

Surveillance is the ongoing systematic

• Can public health action be taken ?

• Are relevant data easily available ?

• Is it worth the effort (money,

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

• Epidemic (outbreak) detection

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

Cases of acute bloody diarrhoea in a rural district by month,

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

Cases of malaria in a region, 1992-1996

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

Probable cases of SARS by date of onset, Viet Nam (n=61*)

WHO Communicable Diseases Surveillance & Response

• What are the levels and trends in HIV infection?

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

Real world! … Analysis &

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

DATA SOURCE (1)

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

• Selected age-group, gender

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

• Private sector, NGOs

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

CASE DEFINITION (1)

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

CASE DEFINITION (2)

WHO Communicable Diseases Surveillance & Response

WHO Communicable Diseases Surveillance & Response

Symptoms Community-based surveillance

Infected Serological survey

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

Event Data Analysis

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

Event Data characteristics

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority

Event Data validation

WHO Communicable Diseases Surveillance & Response

Health Care System Public Health Authority