EPIDEMIOLOGICAL SURVEILLANCE

1. Definition

• Is the systematic collection, analysis,

interpretation and distribution/dissemination
of relevant health data for monitoring the
occurrence and trends of disease in human
population on an ongoing basis.
• Surveillance data provides information for
action.
 2. Objectives of surveillance

2.1 Objectives related to descriptive epidemiology of

health problems
• Monitoring trends is the cornerstone objective of
most surveillance systems
• detection of an increase in adverse health
events can alert health agencies to the need for
further investigation
• When outbreaks or disease clusters are
suspected, surveillance can provide historical
perspective in assessing the importance of
perceived or documented changes in incidence.
 Objectives of surveillance cont…

• permits identification of groups at highest risk of

disease
• information on specific exposures or behaviors
provides insight into etiology or modes of spread.
• surveillance can guide prevention activities before
the etiology of a disease is defined.
 Objectives of surveillance cont…

• Detection of outbreaks is an often-cited use of

surveillance
• data may also be collected on the characteristics of
the disease itself, such as the duration, severity,
method of diagnosis, treatment, and outcome.
• This information provides a measure of the impact of
the disease and identification of groups in whom the
illness may be more severe.
• By describing where most cases of a disease occur or
where disease rates are highest, surveillance provides
another means of targeting public health
interventions.
 Objectives of surveillance cont…
2.2. Objectives linked to services
• At community level, surveillance is often an
integral part of the delivery of preventive and
therapeutic services by health departments.
• This role is particularly true for infectious
diseases where interventions are based on
known modes of disease transmission, where
therapeutic or prophylactic interventions are
available, and thus where receipt of a case
report triggers a specific response.
Objectives of surveillance cont…
For example, Report of a case of tuberculosis
would trigger an effort to identify potential
contacts in the home, workplace, or school,
who would benefit from skin test screening
for tuberculosis exposure and potentially from
prophylactic therapy.
 Objectives of surveillance cont…
2.3. Objectives linked to research
Surveillance can provide an important bridge
to researchers by providing clues for further
investigation
 
 Objectives of surveillance cont…
2.4. Objectives related to evaluation of interventions
• Evaluation of the effect of public health interventions
is complex.
• By observing trends in the numbers or rates of
events or the characteristics of affected persons,
surveillance may provide a comparatively
inexpensive and sufficient assessment of the impact
of intervention efforts
 Objectives of surveillance cont…
2.5. Objectives related to projection
• Planners need to anticipate future demands
for health services
• Observed trends in disease incidence,
combined with other information about the
population at risk, can be used to estimate
future trends
 Objectives of surveillance cont…
2.6. Objectives related to education and Policy
Surveillance data are important for:
- implementing public health programs
-health advocacy
-monitoring and evaluating programs
- health planning
 Objectives of surveillance cont…
• it is essential that they be widely and effectively
disseminated, not only to those who participate
in their collection, but also to the full
constituency of persons who can use them,
including the public health, the media, and
political leaders.
• This information educates those directly
responsible for providing health care and those
who control or influence the allocation of health
resources
 3. ELEMENTS OF SURVEILLANCE SYSTEM

a) Case definition
• Defining a case is a fundamental step in the
development of a surveillance system
• surveillance definitions must balance
competing needs for sensitivity, specificity,
and feasibility
• Because of the need for simplicity,
surveillance case definitions are typically brief
 Elements of surveillance system cont…

• When the definitions apply to diseases, they

generally combine laboratory criteria with
clinical manifestations
• For some diseases, definitions may be
stratified by the level of confirmation, e.g
confirmed and possible cases, depending on
available information
 Elements of surveillance system cont…

• For surveillance of health related behaviors or

exposures, surveillance definition may depend on
self-reports, observation, or specimen collection
and measurement
• For an individual disease or health problem, no
single definition is ideal.
• appropriate definitions vary widely in different
settings depending on information needs,
methods of reporting or data collection, and staff
training
 Elements of surveillance system cont…

•  For example surveillance definitions for

Hepatitis A, ranges from “Yellow eyes” to a
definition that requires documentation of
specific acute phase antibodies to the
hepatitis A virus combined with clinical signs
of jaundice or laboratory evidence of liver
dysfunction.
• The first definition is very simple and could be
used by field staff with minimal training
 Elements of surveillance system cont…

• The second definition is appropriate in a

developed country where diagnostic testing is
routinely done to distinguish hepatitis types of A,
B, and C
• For diseases with long latency or a chronic
course, developing a case definition can be more
complicated
• First a decision must be made regarding which
phase to monitor: asymptomatic, early disease,
late disease, death.
 Elements of surveillance system cont…

• Often, monitoring disease is insufficient, and

there is a need to monitor exposure or
behaviors that predispose to disease
• Exposures also need to be defined.
 Elements of surveillance system cont…

b) Population under surveillance

All surveillance systems target specific

populations, which may range from
individuals at specific institutions, to residents
of a community, to residents of a nation, etc.
 Elements of surveillance system cont…

c) Cycle of surveillance

• Surveillance systems can be described as information loops,

with information coming into the collecting organization
and information being returned to those who need it
• the loop is complete when the information is applied
• The elements of a typical surveillance loop begin with the
occurrence of a health event, its detection by a health care
provider, notification of health agency (with successive
transfer of information from local to central agencies),
analysis and interpretation of aggregate data, and
dissemination of the results.
 Elements of surveillance system cont…

d) Confidentiality
• Personal identifying information is necessary to
identify duplicate reports, to obtain follow-up
information when necessary, to provide services
to individuals, and to use surveillance as the basis
for detailed investigations
• Protecting the physical security and
confidentiality of surveillance records is both an
ethical responsibility and a requirement for
maintaining the trust of participants
 Elements of surveillance system cont…

• Procedures to protect security include limiting

access of personnel to sensitive data, adequate
locks for rooms and files where data are
stored, and use of passwords and other
security measures in computer systems
• As a safeguard against violation of
confidentiality, personal identifying
information should not be kept when it is not
needed.
 Elements of surveillance system cont…

• While personal identifying information may be

needed at the local level, it is generally not
necessary for that information to be
forwarded to more central agencies.
• In such cases codes can be used
 Elements of surveillance system cont…

e) Incentives to participation
• Successful surveillance systems depend on
effective collaborative relationships and on the
usefulness of the information they generate
• Providing information back to those who
contribute to the system is the best incentive to
participation
• This feed back may be in the form of reports and
seminars
 Elements of surveillance system cont…

• Documenting how surveillance data are used

to improve services or shape policy
emphasizes to participants the importance of
their cooperation
• Other incentives may be more immediate,
such as payment for case reports
• For individuals who participate in surveys,
respondents may be paid for their time and
willingness to provide blood or other
specimens
 4. TYPES OF SURVEILLANCE

There are three major types of surveillance:

A. Passive Surveillance
B. Active Surveillance
C. Sentinel Surveillance
 Types of surveillance cont…

1) Passive surveillance/ passive case detection

• Is a mechanism for routine survey based on passive
case detection and on the routine recording and
reporting system.
• The information provider comes to the health
institutions for help, be it medical or other.
• It involves collection of data as part of routine
provision of health services.
 Types of surveillance cont…
Advantages

• covers a wide range of problems

• does not require special arrangement
• it is relatively cheap
• covers a wider area
 Types of surveillance cont…
Disadvantages
• The information generated is to a large extent
unreliable, incomplete and inaccurate
• Most of the time, data from passive surveillance is
not available on time
• Most of the time, you may not get the kind of
information you desire
• It lacks representativeness as it is mainly from health
institutions
• There is no feed back system
 Types of surveillance cont…
2. Active surveillance
• is a method of data collection usually on a specific
disease, for relatively limited period of time.
• It involves collection of data from communities such as
in house-to-house surveys or mobilizing communities
to some central point where data can be collected.
• This can be arranged by assigning health personnel to
collect information on presence or absence of new
cases of a particular disease at regular intervals.
 Types of surveillance cont…
• Example: investigation of out-breaks
• The techniques employed to collect
information for active surveillance are:
-Sending out a letter describing the situation
and asking for reports,
-making a telephone call
- visit the facilities to collect information on
cases.
 Types of surveillance cont…
-Alerting the public directly, usually through local
media, to visit a health facility if they have symptoms
compatible with the disease in question.
-Asking patients of the particular disease if they know
anyone else with the same condition.
-Conducting a survey of the entire population.
 
Advantages
• the collected data is complete and accurate
• information collected is timely.
 Types of surveillance cont…
Disadvantages
• it requires good organization,
• it is expensive
• requires skilled human power
• it is for short period of time(not a continuous
process)
• it is directed towards specific disease
conditions
 Types of surveillance cont…
Conditions in which active surveillance is
appropriate
• Because of its limitations, active surveillance has
limited scope and lacks continuity.
• Therefore certain conditions have to be fulfilled in
order to institute an active surveillance system.
• These conditions are:
-For periodic evaluation of an ongoing program
 Types of surveillance cont…
-For programs with limited time of operation such as
eradication program.
-In unusual situations such as
.New disease discovery
.New mode of transmission
.When a high-risk season/year is recognized.
.When a disease is found to affect a new
subgroup of the population.
.When a previously eradicated disease reappears.
 Types of surveillance cont…
3) Sentinel Surveillance
• uses a pre-arranged sample of reporting sources to
report all cases of one or more conditions.
• Usually the sample sources are selected to be those
most likely to see cases of the specified condition.
• provides a practical alternative to population-based
surveillance, in developing countries.
• health officials define homogenous population
subgroups and the regions to be sampled.
• They then identify institutions that serve the
population subgroups of interest, and that can and will
obtain data regarding the condition of interest.
 Types of surveillance cont…
Advantages
• relatively inexpensive
• provides a practical alternative to population-based
surveillance
• can make productive use of data collected for other
purposes
Disadvantages
• the selected population may not be representative of
the whole population
• use of secondary data may lead to data of lesser
quality and timeliness
 5. Activities in Surveillance

The different activities carried out under

surveillance are:
• Data collection and recording
• Data compilation, analysis and interpretation
• Reporting and notification
• Dissemination of information
 Activities in Surveillance cont…
Data Collection and recording
• each case should be recorded.
• All the necessary information such as age, sex,
address, educational level, occupation, contact,
past history, environmental conditions, diagnosis
of the health problem, vaccination or treatment,
place of infection, sources of infection, exposure
status and any other relevant information that
you think necessary should be well recorded.
•  
 Activities in Surveillance cont…
• Basic techniques of data collection include the
following:
• Record review
• Interviews
• Surveys using questionnaires, and
• Observation.
 Activities in Surveillance cont…

Recording is the process or the act by which

data are generated.
• Usually records are written information kept
in notebooks or in folders;
• may also be kept on tapes or in computers.
• Recording for surveillance, as well as any
recording, must be time, person, place specific
and should include all information necessary
for the event.
 Sources of data for surveillance

A wide variety of sources are available

• Mortality registration
• Morbidity registration
• Epidemic reporting
• Reports of laboratory utilization (Including lab test results)
• Reports of individual case investigations
• Reports of epidemic field investigations
• Special surveys
• Information on animal reservoir and vector distribution
 Data compilation, analysis and interpretation

• The data should be collected at each level of the health care

delivery system
• Each level makes sure that the quality of information
collected at facility, field or anywhere should be accurate,
complete, reliable, and submitted on time.
• Analysis of surveillance data involves comparing current data
with some expected value
• Analysis of data must be made at every level of the health
delivery system.
• Analysis at the health facility level helps to recognize
problems timely and to take appropriate action immediately.
 Reporting and notification

• Reports are the information communicated to the

other level of the health service.
• Reporting in surveillance is done using different
formats designed for this purpose.
• Reporting formats must be clear and easy to use as
data collection forms but make sure that they
contain information appropriate for the level of the
person collecting the information.
• Any report must answer questions like what, where,
when, to whom, for what and why.
 Types of reports

• Oral: - passing information verbally and the

sender must check that the message is
correctly understood by the receiver.
• Radio or telephone-for special cases like
emergency situations.
• Written - in normal circumstances.
 Dissemination of information

• Dissemination of reports to those who need to

know is an important function of public health
surveillance.
• In general a surveillance report serves two major
purposes. These are information and motivation.
• To ensure that reporters at various levels remain
motivated and actively involved in the
surveillance program, there must be a regular
feedback from higher levels.
 6. Attributes of surveillance

• Surveillance systems can be judged using a list of

attributes (CDC 1988).
• This list can be used to evaluate an existing system or
to conceptualize a proposed system
• Because the attributes are conflicting, it is necessary
to determine which are the most important for a
given system
• Efforts should be invested in strengthening those
aspects of the system that addresses the important
attributes, while accepting that others cannot be
fully achieved.
 Attributes of surveillance cont…

These attributes are:

a) sensitivity – to what extent the system identify all of
the events in the target population?
b) Timeliness – This attribute refers to the entire cycle
of information flow, ranging from information
collection to dissemination
•  the need for timeliness depends on the public health
urgency of a problem and the types of interventions
that are available
 Attributes of surveillance cont…
C) Representativeness – To what extent do
events detected through the surveillance
system represent persons with the condition
of interest in the target population?
-A lack of representativeness may lead to
misallocation of health resources
 Attributes of surveillance cont…

d) Predictive value
• To what extent are reported cases really
cases?
• To what extent are measured changes in
trends truly reflective of events in the
community
 Attributes of surveillance cont…
e) Accuracy and completeness of descriptive
information
• Forms of reporting health events often include
descriptive personal information, such as
demographic characteristics, clinical pattern
of disease, or potential exposures
-To what extent are these sections of forms
completed?
-Is the information sufficiently reliable?
 Attributes of surveillance cont…
f) Simplicity

• Are forms easy to complete?

• Are procedures difficult?
• Is data collection kept to a necessary
minimum?
 Attributes of surveillance cont…
g) Flexibility

• Can the system change to address new

questions?
• Can it adapt to evolving standards of diagnosis
or medical care?
 Attributes of surveillance cont…
h) Acceptability
• to what extent are the participants in a
surveillance system (those who report cases,
welcome staff to their hospitals or offices,
complete forms, etc.) enthusiastic about the
system?
• Does the effort they invest yield useful
information?
 7. Limitations of the existing surveillance
system in Ethiopia

The common deficiencies in the national

surveillance system are:
• Deficiencies in data collection
• lack of diagnostic accuracy
• lack of completeness and
• lack of representativeness
 Limitations
•  Deficiencies in reporting/ notification
• multiplicity of case reporting forms
• lack of compliance
• lack of timeliness
• Deficiencies in data analysis:
-carried out at the central rather than local level
-results in national indicators of health status rather than local
indicators
• Deficiencies in dissemination
• aggregate information which is not useful at the local level
• no feedback system
• lack of follow-up for action
 The integrated disease surveillance system

• In this strategy several activities from the

different vertical programs are coordinated
and streamlined in order to make best use of
scarce resources.
• The activities are combined taking advantage
of similar surveillance functions, skills,
resources, and target population.
The integrated disease surveillance system
cont…

Integrated disease surveillance strategy

recommends coordination and integration of
surveillance activities for diseases of public
health importance.
 The integrated disease surveillance system cont…

The diseases are:

• Cholera
• Yellow fever
• Dracunculiasis
• Measles
• Meningococcal meningitis
• Neonatal tetanus
• Plague
• Viral hemorrhagic fever
 The integrated disease surveillance
system cont…
• Malaria
• Diarrhea
• Diarrhea with severe dehydration in under
five years old
• AIDS
• STI
• Onchocerciasis
 The integrated disease surveillance
system cont…
• Bloody diarrhea
• Typhoid fever
• Relapsing fever
• Epidemic typhus
• Pneumonia in under five years old
• Leprosy
• Tuberculosis