PUBLIC HEALTH

SURVEILLANCE

BY

Faraz Siddiqui
Instructor
ION, DUHS
 SURVEILLANCE
WHAT IS SURVEILLANCE ?
DICTIONARY MEANING ?
 “CLOSE OBSERVATION” ESPECIALLY OF ONE
UNDER STATE OF BEING OBSERVED.
POLICE, FBI, CIA, INTELLIGENCE
AGENCIES.
SATELLITES, GIS (GEOGRAPHIC INFO
SYSTEM)
PUBLIC HEALTH SURVEILLANCE.
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 DEFINITION OF PUBLIC HEALTH
SURVEILLANCE

“SURVEILLANCE IS THE ONGOING AND

SYSTEMATIC COLLECTION, ANALYSIS, AND
INTERPRETATION OF DATA AND THE
DISSEMINATION OF INFORMATION TO THOSE
WHO NEED TO KNOW IN ORDER THAT ACTION
MAY BE TAKEN.
SURVEILLANCE MAY PROVIDE BASIS FOR
IDENTIFYING INDIVIDUALS WHO REQUIRE
PROPHYLAXIS, TREATMENT OR EDUCATION.

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WHY SURVEILLANCE IS IMPORTANT

Provides information about occurrence of

disease over time within specific population
(incidence prevalence).
To monitor trends and patterns of disease.
Who is affected?
Who is at risk?
Why?
When?
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 Cont…
Who needs prophylaxis, Treatment or
Education.
To detect sudden changes in disease
occurrence and distribution
To follow trends and patterns of disease
To identify changes in agents and host
factors
To detect changes in health care practices
Important advocacy tool
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 TYPES OF SURVEILLANCE
ACTIVE:
 WE CALL PEOPLE REGULARLY AND ASK FOR POSITIVE
OR NEGATIVE INFORMATION. ORGANIZATION
CONDUCTING SURVEILLANCE INITIATES
PROCEDURES TO OBTAIN REPORTS.
PASSIVE:
 PEOPLE REPORT TO US (CALL OR FILL FORMS OR FAX
OR EMAIL). ORGANIZATION RATHER LEAVES THE
INITIATIVE FOR REPORTING TO OTHERS.

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NOTIFYABLE DISEASE REPORTING

HEALTH DEPARTMENT HAS AUTHORITY TO

DESIGNATE THAT SPECIFIC DISEASES ARE
NOTIFY-ABLE, MEANING THAT BY LAW THEIR
OCCURRENCE MUST BE REPORTED.
Laboratory – Based Surveillance
 DIAGNOSTIC LABORATORIES AS BASIS OF
SURVEILLANCE.

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NOTIFYABLE DISEASE IN PAKISTAN

ACUTE WATER DIARRHEA (AWD)

BLOODY DIARRHEA (BD)
ACUTE RESPIRATORY INFECTION (ARI)
MALARIA
MEASLES
ACUTE JOUNDICE SYNDROME

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 Cont…
ACUTE FLACID PARALYSIS (AFP)
MENINGITIS (MEN)
NEONATAL TATNUS (TET)
ACUTE HEMORRHAGIC (AHF)
UN- explained fever (FUO)
INJURIES (INJ)

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SENTINEL SURVEILLANCE
COLLECTION OF DATA FROM SPECIFIC SITES
(SENTINEL SITES) FROM WHERE DATA CAN BE
EASILY COLLECTED, AND THERE IS
INFRASTRUCTURE AND MOTIVATED STAFF.
 (THE OCCURRENCE OF RARE DISEASE KNOWN TO BE
ASSOCIATED WITH A SPECIFIC EXPOSURE CAN ALERT
HEALTH OFFICIALS TO SITUATION WHERE OTHERS
MAY HAVE BEEN EXPOSED TO A POTENTIAL HAZARDS
SUCH OCCURRENCE HAVE BEEN TERMED SENTINEL
EVENTS.

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 Cont…
COST EFFECTIVE SYSTEM
GOOD FOR DEVELOPING COUNTRIES WITH
LIMITED RESOURCES
WHEN POPULATION BASED SURVEILLANCE
NOT POSSIBLE
UNDER REPORTING OF CASES – PROBLEM
CAN BE EFFECTIVELY ADDRESSED

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 Cont…
CRITERIA FOR SELECTION OF SENTINEL
SITES
SITES ARE NOT SELECTED RANDOMLY
TRAINED HUMAN RESOURCES
MOTIVATION OF STAFF
REQUIRED INFRASTRUCTURE/ EQUIPMENT

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 SOURCES OF DATA
NOTIFYABLE DISEASE REPORTS
BIOLOGICAL AND BEHAVIORAL SURVEYS.
SERO-PREVELLANCE SURVEYS.
KAP SURVEYS.
MORTALITY, MORBADITY AND EPIDEMIC
REPORTS
VITAL STATISTICS, BIRTH, DEATH,
MARRIAGE AND DIVORCE REGISTER
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 Cont…
DEMOGRAPHIC DATA
ENVIRONMENTAL DATA
VERTICAL PROGRAM REPORTS
HEALTH AND ECONOMIC SURVEYS
BLOOD BANKS DATA
PATHOLOGICAL LABORATORY DATA
CANCER REGISTERY DATA

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 Flow of Surveillance Data

Collection

Dissemination,
Collation
Utilisation

Analysis and
Interpretation
# 1-4-6
INFORMATION LOOPS
A surveillance system is an information loop or
cycle that involves:

 healthcare providers

 public health agencies

 the public

# 1-4-5
OUTBREAK INVESTIGATIONS
THE OBJECTIVE OF AN INVESTIGATION ARE TO:
 DETERMINE THE MAGNITUDE OF ILLNESS.
 Incidence and/or Prevalence
 IDENTIFY THE AGENT CAUSING THE ILLNESS AND THE
RISK FACTORS ASSOCIATED WITH THE ILLNESS.
 Data collection and analysis.
 Hypothesis testing with laboratory support.
 What, Who,Where,When, How & Why ?
 FORMULATE CONTROL MEASURES TO STOP AND
PREVENT THE SPREAD OF THE ILLNESS.
 Reporting and dissemination.
 “Taking the handle off the pump”.

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ELEMENTS OF A SURVEILLANCE SYSTEM

A- CASE DEFINATION
CASE DEFINATION IS A FUNDAMENTAL STEP IN
THE DEVELOPMENT OF A SURVEILLANCE
SYSTEM.
APPROPRIATE DEFINATION VARY WIDELY IN
DIFFERENT SETTINGS, DEPENDING ON
INFORMATION NEEDS , METHODS OF
REPORTING, AND DATA COLLECTION AND STAFF
TRAINING.

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FOR EXAMPLE DEFINITION OF HEPATITIS “A”
COULD BE AS SIMPLE AS “YELLOW EYES” TO A
DEFINITION WHICH REQUIRES DOCUMENTATION
OF SPECIFIC ACUTE PHASE ANTIBODIES TO
HEPATITIS “A” VIRUS, COMBINED WITH
CLINICAL SIGNS OF JAUNDICE OR LABORATORY
EVIDENCE OF LIVER DYSFUNCTION.

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B- POPULATION UNDER SURVEILLANCE

ALL SURVEILLANCE SYSTEMS TARGET

SPECIFIC POPULATIONS, WHICH MAY
RANGE FROM INDIVIDUALS AT SPECIFIC
INSTITUTIONS (E.G. HOSPITALS, CLINICS,
NURSING HOMES, SCHOOLS, PRISONS) TO
RESIDENTS OF A COMMUNITY, TO
RESIDENTS OF A NATION.

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 C- CONFIDENTIALITY
PROTECTING THE PHYSICAL SECURITY AND
CONFIDENTIALITY OF SURVEILLANCE RECORDS
IS BOTH AN ETHICAL RESPONSIBILITY AND
REQUIREMENT FOR MAINTAINING TRUST OF
PARTICIPANTS.
AS A SAFEGUARD AGAINST VIOLATIONS OF
CONFIDENTIALITY PERSONEL RECORD
IDENTIFYING INFORMATION SHOULD NOT BE
KEPT WHEN IT IS NOT NEEDED.

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 COMPONENTS OF A
SURVEILLANCE SYSTEM-I
WHAT IS THE POPULATION UNDER
SURVEILLANCE?
WHAT IS THE PERIOD OF TIME OF THE DATA
COLLECTION?
WHAT INFORMATION IS COLLECTED?
WHO PROVIDES THE SURVEILLANCE
INFORMATION? WHAT IS THE SOURCE?
HOW IS THE INFORMATION TRANSFERRED?
HOW IS THE INFORMATION STORED?
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COMPONENTS OF A SURVEILLANCE
SYSTEM-II

WHO ANALYZES THE DATA?

HOW ARE THE DATA ANALYZED, AND HOW
OFTEN?
ARE THERE PRELIMINARY AND FINAL
TABULATIONS, ANALYSES, AND REPORTS?
HOW OFTEN ARE REPORTS DISSEMINATED?
TO WHOM ARE REPORTS DISTRIBUTED?
HOW ARE THE REPORTS DISTRIBUTED?

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DISSEMINATION OF SURVEILLANCE DATA

THOSE WHO NEED TO KNOW

POLICY MAKERS, PLANNERS
DOCTORS, CARE PROVIDERS
LABORATORIES
THOSE WHO PROVIDE DATA

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HIV/AIDS SURVEILLANCE IN PAKISTAN

CURRENT HIV/AIDS SURVEILLANCE

SYSTEM IN PAKISTAN INCLUDES
FOLLOWING :
1) PASSIVE REPORTING FROM PUBLIC &
PRIVATE HEALTH CARE FACILITIES
(NOTIFIABLE).
2) SENTINEL SURVEILLANCE
A) HIV/AIDS TESTING & COUNSELING
CENTERS
B) STDS CLINICS
C) BLOOD BANKS
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3) Periodic National Sero-prevalence Surveys
 HIGH RISK GROUPS
 LOW RISK GROUP

4) Second Generation Surveillance System

 Integrated Biological and Behavioral Surveillance (IBBS).

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HIV/AIDS REPORTED CASES: IN SINDH OF DEC 2009

HIV Positive 2498

AIDS 179

Total 2677
Deaths 56

Total Reported Cases of HIV/AIDS 5722

in Pakistan March 2009
Source: NACP
WHAT IS SECOND GENERATION
SURVEILLANCE SYSTEM?

Integrating behavioral risk surveillance in

biological surveillance
Targets high risk groups (Most at Risk)
Links HIV data
Ideal for countries with low or concentrated
HIV epidemics
More sensitive and more flexible

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 MOST AT RISK GROUPS
Injecting Drug Users
Female Sex Workers
Male Sex Workers
Hijras (Training Generalized)
Prisoners
Long distance Truck drivers

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WHAT WAS WRONG WITH 1ST
GENERATION SURVEILLANCE?

High risk groups not covered

STI patients/donors who came themselves
were included
Only biological information collected
Biological data inadequate to develop
appropriate preventive programs or policies.

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HOW DOES IBBS WORK?
Mapping

Results used for developing sampling

strategy for each high risk group

Interviews conducted at different sites for each high risk group

Behavioral & Biological

Data Management & Analysis

Report Writing/Submission
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Data generated
Mapping of High risk groups
 Quickly identifies the locations and size of key populations
(e.g. sex workers, IDUs)
 also identifies the various sub typologies of each HRGs

Integrated behavioural and biological surveillance

 Determines the risk and protective behaviours of key
population members
 Determines the distribution of HIV in key population groups

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MAPPING DATA
 List of Spots for each HRG in each zone/area
 Spot Maps

This information is used in IBBS for

 Developing a sampling frame
 Proportional allocation of the sample for
each typology
 Probability sampling
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Major indicators used in HIV
surveillance: a summary
Biological indicators
 HIV prevalence
 STD prevalence
 Hepatitis B and C prevalence
 TB prevalence
 Number of adult AIDS cases
 Number of Paediatric AIDS cases

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 (Cont..)
Behavioural indicators
Sex with a non-regular partner in the last 12
months
Condom use at last sex with a non-regular
partner
Youth: age at first sex
Drug injectors: Reported sharing of unclean
injecting equipment
Sex workers: Reported number of clients in
the last week
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 (Cont..)
Socio-demographic indicators
·  Age
·  Sex
·  Socio-economic or educational status occupation
or years of schooling)
·  An indicator of residency or migration status
·  Parity (for antenatal sites)
·  Marital status
 

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 HIV among IDUs in Pakistan (Round 3, 2008)
City Tested Positive Prevalence (95% CI)
Karachi 403 93 23.1%
Hyderabad 397 121 30.5%
Sukkur 399 21 5.3%*
Larkana 389 111 28.5%
Lahore 401 58 14.5%
Faisalabad 400 49 12.3%
Multan 400 0

Gujranwala 400 4 1%*

Sargodha 403 92 22.8
Peshawar 231 30 12.8%
Bannu 72 1 1.4%
Quetta 190 18 9.5%*
Total 4085 598 14.6%
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Sero prevalence from National Report 2006-7 (Round 2)NACP/HASP Round-I
 HIV among MSWs and HSWs in Pakistan (Round 3, 2008)
MSWs HSWs
City Tested Positive Prevalence Tested Positive Prevalenc
e
Karachi 197 6 3.1% 222 8 3.6%
Hyderabad 199 0 0 198 0 0
Sukkur 200 0 0 200 0 0
Larkana 200 1 0.5% 199 55 27.6%
Lahore 202 2 1.0% 201 5 2.5%
Faisalabad 202 0 0 200 5 2.5%
Multan 200 1 0.5%* 200 1 0.5%*
Gujranwala 200 0 0 200 1 0.5*
Sargodha 200 2 1% 200 1 0.5%*
Peshawar 200 0 0 161 2 1.2%
Bannu 100 4 4% 35 2 5.7%*
Quetta 177 0 0 187 0 0
Total 2277 16 0.7% 2203 80 3.6%
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*Sero prevalence from National Report 2006-7 (Round 2)
 EPIDEMIC
LOW LEVEL
Principle: Although HIV infection may have existed
for many years, it has never spread to significant
levels in any sub-population.
Recorded infection is largely confined to individuals
with higher risk behaviour: e.g. sex workers, drug
injectors, men having sex with other men. This
epidemic state suggests that networks of risk are
rather diffuse (with low levels of partner exchange or
sharing of drug injecting equipment), or that the virus
has been introduced only very recently.
Numerical proxy: HIV prevalence has not
consistently exceeded five percent in any defined sub-
population. 39
CONCENTRATED
Principle: HIV has spread rapidly in a defined
sub-population, but is not well-established in
the general population. This epidemic state
suggests active networks of risk within the
sub-population. The future course of the
epidemic is determined by the frequency and
nature of links between highly infected sub-
populations and the general population.
Numerical proxy: HIV prevalence
consistently over five percent in at least one
defined sub-population. HIV prevalence below
one percent in pregnant women in urban
areas.
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GENERALISED
Principle: In generalised epidemics, HIV is
firmly established in the general
population. Although sub-populations at
high risk may continue to contribute
disproportionately to the spread of HIV,
sexual networking in the general
population is sufficient to sustain an
epidemic independent of sub-populations
at higher risk of infection.

Numerical proxy: HIV prevalence

consistently over one percent in pregnant
women nationwide.
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