By Hatim Jaber MD MPH JBCM PhD 11- 12- 2017 Faculty of Medicine Introduction to Community Medicine Course (31505201) Public Health Surveillance By Hatim Jaber MD MPH JBCM PhD 11- 12- 2017

Number of people affected by dementia to triple in next 30 years

Post midterm Causation Week 8 Unit 6: Demography and Data Week 9  Midterm assessment (Exams.)15-11-2017 Week 10 Unit 8 Introduction to Epidemiology. Week 11 Unit 9: Prevention and Control of Diseases Causation Week 12 Unit 10: Communication and Health Education Week 13 Unit 11: Public Health Surveillance and Screening Week 14 Unit 12: Health Administration and healthcare management Week 15 Unit 13: Revision and Health Research Week 16 Final assessment (Exams.) 4-1-2018

Presentation outline Definitions of surveillance Time Definitions of surveillance 08:00 to 08:15 Objectives of surveillance Public health vs health care surveillance 08:15 to 08:30 Elements of a surveillance system 08:30 to 08:45 Surveillance methods 08:45 to 09:00 Surveillance system in Jordan 09:00 to 09:15

Data Sources: Population Census Vital registration system Sample household surveys Special population surveys Demographic (elderly, youth) Risk groups ( IDUs) Occupational (farmer, skilled labor) Area-based (catastrophe-affected) Biomarkers

Types of Information Surveillance Routine service reporting Epidemiological Behavioral Routine service reporting Special program reporting systems Administrative systems Vital registration systems Facility surveys Household surveys Censuses Research and special studies

“Surveillance”

The word “Surveillance” The word "sur-veillance" means (in French) "to watch from above" ("veiller" = "to watch" and "sur" = above") (i.e. a God's-eye view looking down from on-high) The term is often used for all forms of observation, not just visual observation.

Definition of Surveillance Public health surveillance (sometimes called epidemiological surveillance) is : the ongoing systematic collection, analysis, and interpretation of outcome-specific data essential to the planning, implementation, and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know. Outcomes may include diseases, injury, and disability, as well as risk factors, vector exposures, environmental hazards, or other exposures. The final link of surveillance chain is the application of these data to prevent and control human diseases and injury.

Surveillance Principle “If you don't use it, then do not ask for it!” Surveillance is: “Information for Action” “If you don't use it, then do not ask for it!” However: “Good surveillance does not necessarily ensure the making of the right decisions, but it reduces the chances of the wrong ones” A. D. Langmuir (1963)

History In 1950, the term “surveillance” was restricted to public health practice to watching contacts of serious communicable diseases” To early detect symptoms To institute prompt treatment Example: Smallpox

Surveillance, surveys, registries and HMIS: Surveillance is systematic ongoing collection, collation, and analysis of data, and the timely dissemination of information to those who need to know so that action can be taken A survey is a one data collection episode Registries are not for immediate action Health Management Information Systems (HMIS) for annual reports

What is Public Health Surveillance? -Continued Who Performs Public Health Surveillance? Epidemiologists Medical professionals (doctors, nurses, clinics) Pharmacies Health insurance providers Emergency responders Public health departments (local, state, federal) Surveillance provides the information for descriptive epidemiology, which is Person (age, sex, description) Place (where) Time (dates, hours, days, months, years)

Note the Differences: Registers are archival health information Surveillance is dynamic as compared with surveys: Interplay between epidemiologic studies and control activities Surveillance is not mere: Reporting Monitoring Data collection

Continuous versus Periodic Data Collection Continuous Data Collection Small team Large team or multiple teams Data accessibility Initially slow Faster turnaround Data usefulness for trend analysis Ongoing results Results only after three rounds of data collection Evaluation of health intervention Continuous monitoring of impact Timing of collection often not linked to intervention Budget Line item in health budget One-off investment at each cycle

Public health vs health care surveillance protection, promotion, and restoration of health of population includes health care services, especially if publicly-funded Health care services provided to individuals or communities by agents of health services or professionals to promote, maintain, monitor, or restore health. Not limited to medical care (therapy by MD)

Public health vs health care surveillance (cont’d) may be part of public health surveillance (e.g., Montreal DSP) also conducted by other agencies and/or health care organizations (e.g., hospitals) Population may differ public health: usually defined geographically (district, region, country) health care: recipients of services or catchment population

Goals and Uses of Surveillance Detect outbreaks or epidemics Detect changes in trends over time, portray natural history of diseases Evaluate control measures Estimate magnitude of morbidity and mortality Ensure equity in health care (mortality and morbidity) Facilitate planning Making projections, understanding burden of disease and justifying allocation and or redirection of resources Stimulate epidemiologic research Generate/ Test hypotheses (e.g. changes in health practice) Identify risk factors (in-depth studies)

Objectives of Surveillance Early detection and prediction of outbreaks Description of the magnitude of disease Understanding risk factors for diseases Monitoring trends of endemic disease Monitor programme performance and progress towards a control objective Estimate future disease impact

Surveillance objectives Surveillance should be SMART... S - Specific (regarding event which is subject of ) M - Measurable (gain info for comparison ) A - Action oriented (information for action) R - Realistic & (feasible in time and place) T - Timely (action implemented in time to be effective) Setting objectives – balance between requirements and interests!

Added values of Surveillance High-quality surveillance increases credibility of public health care providers: Encourages transparency Reduces over-reaction Attract donors Encourages implementation of new interventions; new conjugate meningococcal vaccines Facilitates better management of disease control and other public health programs SAVES LIVES !!!!

Importance of Good Reporting Health Care System Public Health Authority Reporting Event Data Analysis & Interpretation Evaluation Feedback Information Intervention

Delayed Detection Means =Delayed Response Early Detection… Early warning indicators: Count of cases (?) Attack rates (stratified) Case-fatality rates Temporal component Defined thresholds Notification of cases Suspect and probable Case-based data Immediate or weekly

Where Do We Get Public Health Surveillance Data? Vital records Hospital records, death certificates, birth records Surveys Schools, doctors, insurance companies Environmental monitoring systems Water or air quality Animal health data Veterinarians, farms, food manufacturing

Types of Surveillance Active vs. Passive Surveillance Active Surveillance: Health department solicits reports Passive Surveillance: Reports are initiated by source for data

Passive surveillance; Routine surveillance where reports are awaited and no attempt make actively seek reports from the participants in the system.

Routine and sentinel surveillance Sentinel surveillance; The surveillance of a specified health event in only sample of the population at risk using a sample of possible reporting sites. The sample should be representative of the total population at risk. Passive surveillance; Routine surveillance where reports are awaited and no attempt make actively seek reports from the participants in the system.

Sentinel Surveillance Often provides an early alert for outbreaks Most useful for diseases that occur frequently Not intended to capture all cases Focal points: Clinics, hospitals or laboratories Strategic locations Representative to population (socio-demographic) High risk groups Less sites but better quality of data bring attention to problems in practices, procedures or systems Useful for research activities

Aggregate surveillance; The surveillance of a disease or health event by collecting summary data on groups of cases (e.g. in many general practice surveillance schemes clinicians are asked to report the number of cases of a specified diseases seen over a period of time).

Case-based surveillance; The surveillance of a disease by collecting specific data on each case (e.g. collecting details on each case of Acute Flaccid Paralysis in polio surveillance) Cluster; The occurrence of an unusual number of cases in person, place

Community surveillance; Surveillance where the starting point is a health event occurring in the community and reported by a community worker or actively sought by investigators. This may be particularly useful during an outbreak and where syndromic case definitions can be used. Comprehensive surveillance; The surveillance of a specified disease or health event in the whole population at risk for that event.

Enhanced surveillance; The collection of additional data on cases reported under routine surveillance. The routine surveillance is a starting point for more specific data collection on a given health event. This information may be sought from the reporter, the case, the laboratory or from another surveillance data set. Intensified surveillance; The upgrading from a passive to an active surveillance system for a specified reason and period (usually because of an outbreak). It must be noted that the system becomes more sensitive and secular trends may need to be interpreted carefully.

Syndromic Surveillance Syndrome is a complex of symptoms Syndrome is constellation of signs and symptoms! Syndromic surveillance focuses on one symptom or constellation of symptoms (clinical outcomes) rather than a diagnosed disease No need of laboratory confirmation. Hence fast. More sensitive, but less specific Faster public health interventions For Example – WHO ALERT system for early detection of outbreaks is syndromic S. SS is surveillance for AFP (syndrome, clinical outcomes) in order to capture possible cases of poliomyelitis.

Surveillance of Disease vs. Persons “ The continuing scrutiny of all aspects of occurrence and spread of disease that are pertinent to its effective control” Surveillance of Persons: “ The continuing scrutiny of disease contacts, high risk groups in order to promote prompt recognition of infection or illness”

Elements of a surveillance system Case definition Indicators Population under surveillance Cycle of surveillance Confidentiality Incentives to participation

Case definition; A set of diagnostic criteria that must be fulfilled to be regarded as a case of a particular disease. Case definitions can be based on clinical criteria, laboratory criteria or a combination of the two. A case definition is a set of criteria that triggers reporting

Elements of surveillance system: case definition Requirements Indicator (not diagnostic) of trends Simple Feasible Reliable Inexpensive Examples Measles: fever with red rash, red eyes, disappearing within a week Cholera: Sudden and severe watery diarrhoea, with rapid and massive dehydration Malaria: Fever, rigors, headache, body aches, inability to carry out normal daily activities

Case definition YES NO - A “case” is an event - An event is something that happens to: A person, In a given place, At a given time - A case definition is a set of criteria that triggers reporting NO - A “case” is not a person - Events do not exist if you lack info: On the person On the place On the onset date - A case definition is not a diagnosis made to decide treatment

Case definition Includes: Should be: Time, place, person. Clinical features and /or Laboratory results and/or Epidemiological features Should be: Clear, simple Field tested Stable and valid Adopted

Case definition--three-level definitions Meningococcal disease (SURVEILLANCE PURPOSES) Possible case Clinical diagnosis of meningitis or septicaemia or other invasive disease where the consultation with the clinician and microbiologist, considers that diagnoses other than meningococcal disease are at least as likely Probable case Clinical diagnosis of meningitis or septicaemia or other invasive disease where the consultation with the physician and microbiologist, considers that meningococcal infection is the most likely diagnosis Confirmed case Clinical diagnosis of meningitis, septicaemia or other invasive disease AND at least one of: Neisseria meningitidis isolated from normally sterile site Gram negative diplococci in normally sterile site Meningococcal DNA in normally sterile site Meningococcal antigen in blood, CSF or urine.

Elements of surveillance system: population under surveillance Population-based Institution-based hospitals, practices, nursing homes, prisons, schools Combinations e.g., Drug Abuse Warning Network (DAWN) in US: morbidity and mortality data on illicit drug use from hospital ERs and medical examiners/coroners

Elements of surveillance system: cycle of surveillance Occurrence of health event Detection by health care provider Notification of health agency Analysis and interpretation Dissemination

Elements of surveillance system: confidentiality Legally mandated reporting requires confidentiality precautions limited access to data (locks, passwords etc) encryption algorithms for coding names Perceived lack of confidentiality a major deterrent to completeness of reporting STDs drug use

Cross-sectional vs longitudinal Surveillance methods Active vs passive methods Legally notifiable diseases Sentinel events Sentinel surveillance Cross-sectional vs longitudinal

Surveillance methods: longitudinal vs cross-sectional Ongoing data collection Incident cases Examples: notifiable diseases, vital statistics, disease registries Cross-sectional Serial surveys

Levels of Surveillance National: Periphery: (e.g., PHCC catchment area, city) Intermediate: Provincial Central International: International Health Regulations 2005

Special Surveillance Programs Natural and man-made disasters (emergencies) During Special events of mass gatherings (Pilgrims to Makkah Olympics Laboratory-based surveillance: Emerging pathogens Antimicrobial resistance Infection control Behavioural risk factors Others

Systems of Disease Surveillance Notifiable disease reporting systems Laboratory-based surveillance Hospital-based surveillance Population-based surveillance Vital records (birth and death certificates) Registries

DEFINITIONS Disease notification is a process of reporting the occurrence of disease or other health-related conditions to appropriate and designated authorities. A notifiable disease is any disease that is required by law to be reported to government authorities. 

A notifiable disease is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the prevention and control of the disease. Physicians are required by law to report cases of certain infectious diseases. Unfortunately, many do not.

Surveillance Definitions Active case-finding; The dynamic identification of the occurrence of a disease or health event under surveillance. (e.g. house visits by community workers to identify cases of tuberculosis). Active surveillance; Routine surveillance where reports are sought dynamically from participants in the surveillance system on a regular basis (e.g. telephoning each participant monthly to ask about new cases).

Surveillance sensitivity; The ability of a surveillance system to detect an outbreak. (The proportion of all outbreaks that could have been detected by the system). Surveillance predictive value; The likelihood that an “outbreak” detected by a surveillance system is truly an outbreak

Survey; An investigation in which information is systematically collected. It is usually carried out in a sample of a defined population group and in a defined time period. Unlike surveillance it is not ongoing though it may be repeated. If repeated regularly surveys can form the basis of a surveillance system. Zero reporting; The reporting of zero cases when no cases have been detected by the participant.This allows the next level of the system to be sure that the participant has not sent data that has been lost or has forgotten to report.

The following should be addressed for each disease under surveillance: is the case definition:- clear? appropriate? consistent throughout the surveillance system? is the reporting mechanism: clear ? efficient? of appropriate reporting periodicity? available to all relevant persons and institutions? is the analysis of data : appropriate? susceptible to proper presentation? used for decision-making?

do the personnel involved: have a good understanding of the value of the surveillance system? understand, show interest in, and support, their own surveillance task? have enough appropriate human and material resources? do the personnel involved receive appropriate: training? supervision? is the feed-back from intermediate and central levels: appropriate? sufficient? motivating? When the assessment of current activities is done, the next question is: · Is there an operational control program for each of the priority diseases?

Reporting Channels

CHAIN OF REPORTING HCP DNO LG MOH WHO/CDC FMOH SMOH Key: HCP: Health care providers DNO: Disease notification officer LG MOH: Local Government Medical Officer of Health SMOH: State Ministry of Health FMOH: Federal Ministry of Health

Notification A notification is the reporting of certain diseases or other health-related conditions by a specific group, as specified by law, regulation, or agreement. Notifications are typically made to the state or local health agency.

Integrated Disease Surveillance and Response (IDSR) IDSR form 001: For immediate/case based reporting of diseases. Immediate reporting allows for timely action to be taken to prevent the re-emergence or rapid transmission of epidemic prone diseases or events, especially diseases due to highly pathogenic and lethal infectious.

Diseases/Events reported with form IDSR 001 list of diseases/events requiring immediate reporting. Acute Flaccid Paralysis (AFP) Cluster of SARI SARS Diarrhoea with blood (Shigella) Smallpox Acute hemorrhagic fever syndrome Typhoid fever Dracunculiasis Yellow fever (Ebola, Marburg, Lassa Fever, RVF, Influenza due to new subtype Any public health event of international Crimean-Congo) Maternal death Adverse event following immunization Measles concern (infectious, zoonotic, food borne, Meningococcal meningitis chemical, radio nuclear or due to an (AEFI) Neonatal tetanus Anthrax unknown condition) Plague Chikungunya Rabies (confirmed cases) Cholera

IDSR form 002: For weekly reporting of new cases of epidemic/pandemic prone diseases. IDSR form 003: For routine monthly notification of other diseases of public health importance. Integrated Disease Surveillance and Response (IDSR)

Diseases that require monthly reporting Acute viral hepatitis Leprosy (quarterly) Sexually transmitted diseases (STIs) AIDS (New Cases) Lymphatic Filariasis Buruli ulcer Malaria Trachoma Diabetes mellitus Malnutrition in children under 5 years Trypanosomiasis Diarrhoea with severe dehydration in children under 5 years of age Tuberculosis (quarterly) Mental health (Epilepsy) Underweight Newborns (less than 2500 g) HIV (new detections) Noma Onchocerciasis Hypertension Severe pneumonia in children under 5years of age Influenza-like illness Injuries (Road Traffic Accidents)

Reportable Diseases Vary from one country to another Differences within countries Changes over time Adding one single disease to the list could cost a lot: Money, time, avoidable confusion Variables collected should be indicators of potential or arising problems rather than identifying risk factors Report only confirmed cases?

Frequency of Reporting Diseases Weekly? Appropriate most times Monthly? Less sensitive Quarterly? At national level Daily? Daily reporting could be cumbersome Daily reporting may be required during emergencies, disasters Avoid inconsistencies in case definitions Reporting suspected vs. confirmed cases

Data Collection Forms Should be (for line-listing): Simple Minimum content Layout easy to understand Easy to reproduce Special data collection forms: Special surveillance programs (e.g., Malaria, vector control) During outbreaks (Locally acquired or imported?) Eradication activities

Public Health Laboratories Fully linked to epidemiological surveillance Ability to confirm diagnosis of epidemic – prone diseases of national interest Monitor and report selected pathogens Meningococcal meningitis and other bacterial meningitis Cholera, Shigellosis and salmonellosis Viral Hemorrhagic fevers, etc Monitor antimicrobial resistance

Information Loop of Public Health Surveillance Summaries, Interpretations, Recommendations Reports Health Agencies Health Care Providers Public Analysis

Essential activities of surveillance Identify; define and measure the health problem of interest; Collect and compile data about the problem (and if possible, factors that influence it) Analyze and interpret these data Provide these data and their interpretation to those responsible for controlling the health problem and Monitor and periodically evaluate the usefulness and quality of surveillance to improve it for future use. N.B surveillance of a problem does not include actions to control the problem.

Key Indicators Absolute numbers Proportions Rates Percentages Threshold

Information Management

Evaluation of Surveillance Systems

Goals of Evaluation of Surveillance To improve existing surveillance systems To modify systems because of changes in Priorities Epidemiology Diagnostics To optimize the use of available resources

International Health Regulations 2005 Current: Notification to WHO of a case of cholera, plague or yellow fever IHR 2005 Public health emergencies of international importance Obligation to establish core capacities Assistance to States Context specific & flexible recommended measures External advice (emergency and review committees) regarding IHR

National Notifiable Disease Surveillance Reporting mandated by state law/regulation Health care providers, laboratories report to local HD (county) County HD submits reports to State Reports transmitted to CDC primarily through National Electronic Telecommunications System for Surveillance (NETSS)

Map of 54 clinics that participated in the public health surveillance project between May – December 2014 (indicated by red dots)

Mortality surveillance

Influenza: laboratory surveillance

Evaluate control measures of MEASLES United States, 1963-1998 50 100 150 200 250 300 350 400 450 500 Vaccine licensed MEASLES — by year, United States, 1983–1998 5 10 15 20 25 30 Year 1983 1988 1993 1998 Reported Cases (Thousands) Reported Cases (Thousands) 20 10 Source: CDC. Summary of notifiable diseases. 1998. 1963 1968 1973 1978 1983 1988 1993 1998 Year

Table of diseases, conditions and events reported in the public health surveillance project

Table of diseases, conditions and events reported in the public health surveillance project

Proportional morbidity of reported communicable disease cases, excluding acute diarrhoea and chicken pox, through the public health surveillance system between May – December 2014

Figure 5.7 Reported Cases of Salmonellosis per 100,000 Population, By Year — United States, 1972–2002 Figure 5.8 Reported Cases of AIDS, by Year — United States* and U.S. Territories, 1982–2002 Source: Centers for Disease Control and Prevention. Summary of notifiable diseases–United States, 2002. Published April 30, 2004, for MMWR 2002;51(No. 53): p. 59. Total number of AIDS cases includes all cases reported to CDC as of December 31, 2002. Total includes cases among residents in the U.S. territories and 94 cases among persons with unknown state of residence. Source: Centers for Disease Conrol and Prevention. Summary of notifiable diseases–United States, 2002. Published April 30, 2004, for MMWR 2002;51(No. 53): p. 59.

Measles/rubella incidence in Macedonia and immunization schedule changes in the period 1967-1997

Remember…. Surveillance is information for action!