What have we learned in the last two weeks Key take home messages from the Integrated Disease Surveillance Programme (IDSP) district surveillance officers (DSO) course

Surveillance: A role of the public health system The systematic process of collection, transmission, analysis and feedback of public health data for decision making Surveillance DataInformation Action Analysis Interpretation

A dynamic vision of surveillance Collect and transmit data Analyze data Feedback information Make decisions All levels use information to make decisions Surveillance The private sector can treat patients but only the public sector can coordinate surveillance

Type of data: Summary Qualitative Binary NominalOrdinal SexNationalityStatus MYemenMild MJordanModerate FYemenSevere MJordanMild FSudanModerate FYemenMild MSudanModerate MIranSevere FJordanSevere M IranMild FYemenModerate FSudanModerate M IranMild MYemenSevere MJordanSevere FJordanModerate M IranMild FSudanMild MYemenMild Quantitative Discrete Continuous ChildrenWeight

Quick definitions of measures of central tendency Mode  The most frequently occuring observation Median  The mid-point of a set of ordered observations Arithmetic mean  Aggregate / sum of the given observations divided by the number of observation

Prevalence – (P) Number of existing cases (old and new) in a defined population at a specified point of time Number pf people with disease at a specified time P = x 10n Population at risk at the specified time In some studies the total population is used as an approximation if data on population at risk is not available Prevalence

Incidence – (I) Number of new cases in a given period in a specified population  Time, (i.e., day, month, year) must be specified Measures the rapidity with which new cases are occurring in a population Not influenced by the duration of the disease Incidence

Reporting units for disease surveillance Public sector (Exhaustive) Private (Sentinel) Rural Sub-centres (SCs) Primary health centres (PHCs) and block PHCs Community health centres (CHCs) Sub-district/district hospitals Indian medicine units Practitioners Hospitals Urban Dispensaries Urban hospitals Public health labs ESI/Railways/Defence facilities Medical colleges Nursing homes Hospitals Medical colleges Laboratories Reporting units

Types of case definitions in use Case definitionCriteriaUsers Syndromic (suspect) Clinical patternParamedical personnel and members of community Presumptive (Probable) Typical history and clinical examination Medical officers of primary and community health centres ConfirmedClinical diagnosis by a medical officer and positive laboratory identification Medical officer and Laboratory staff More specificity Case definitions

Information flow of the weekly surveillance system Sub-centres P.H.C.s C.H.C.s Dist. hosp. Programme officers Pvt. practitioners D.S.U. P.H. lab. Med. col. Other Hospitals: ESI, Municipal Rly., Army etc. S.S.U. C.S.U. Nursing homes Private hospitals Private labs. Corporate hospitals

Chairperson* District surveillance committee District Surveillance Officer (Member Secretary) CMO (Co. Chair) Representative Water Board Superintendent Of Police IMA Representative NGO Representative District Panchayat Chairperson Chief District PH Laboratory Medical College Representative if any Representative Pollution Board District Training Officer (IDSP) District Data Manager (IDSP) District Program Manager Polio, Malaria, TB, HIV - AIDS * District collector or district magistrate District surveillance committee Superintendent of hospitals

Outpatient register Inpatient slip Reporting unit Case Lab slip Inpatient register Lab register Common reporting form P Computer (District) Form L District public health laboratory District surveillance officer Feedback Weekly Immediately +ve slides + sample -ves

Functions of the district surveillance unit Managerial  Implement and monitor all project activities  Coordinate with laboratories, medical colleges, non governmental organizations and private sector  Organize training and communication activities  Organize district surveillance committee meetings Data handling  Centralize data  Analyze data  Send regular feedback Outbreak response  Constitute rapid response teams  Investigate

REC SEX M 2 M 3 M 4 F 5 M 6 F 7 F 8 M 9 M 10 M 11 F 12 M 13 M 14 M 15 F 16 F 17 F 18 M 19 M 20 M 21 F 22 M 23 M 24 F 25 M 26 M 27 M 28 F 29 M 30 M SexFrequencyProportion Female1033.3% Male2066.7% Total % Data Information Distribution of cases by sex Table Graph Why analyze? Data analysis is about data reduction

1. Count, Divide and Compare (CDC): An epidemiologist calculates rates and compare them Direct comparisons of absolute numbers of cases are not possible in the absence of rates CDC  Count Count (compile) cases that meet the case definition  Divide Divide cases by the corresponding population denominator  Compare Compare rates across age groups, districts etc. CDC for TPP

2. Time, place and person descriptive analysis A.Time  Incidence over time B.Place  Map C.Person  Breakdown by age, sex or personal characteristics CDC for TPP

Malaria in Kurseong block, Darjeeling District, West Bengal, India, January February March April May June July August September October NovemberDecember January February March April May June July August September October NovemberDecember January February March April May June July August September October NovemberDecember January February March April May June July August September October NovemberDecember January February March April May June July August September October NovemberDecember Months Incidence of malaria per 10,000 Incidence of malaria Incidence of Pf malaria Interpretation: There is a seasonality in the end of the year and a trend towards increasing incidence year after year Reports TIME: Incidence graph

Attack rate per 100,000 population Pipeline crossing open sewage drain Open drain Incidence of acute hepatitis (E) by block, Hyderabad, AP, India, March-June 2005 Interpretation: Blocks with hepatitis are those supplied by pipelines crossing open sewage drains PLACE: Map

Probable cases of cholera by age and sex, Parbatia, Orissa, India, 2003 NumberofcasesPopulationIncide e 0 to % 5 to % 15to % % % % % Age group (Inyears) > % Male %Sex Female % TotalTotal % Interpretation: Older adults and women are at increased risk of cholera PERSON: Incidence by age and sex CDC for TPP

Components of early warning surveillance DataReports Alert Public health alert AnalyzeFilter ValidateVerify Assess Surveillance: Response Case-based surveillanceEvent-based surveillance Signal Post-outbreak strengthening Evaluate Investigate Control measures Early warning

Progressive response Levels of alert are progressively increasing Unusual signals require filtering / validation The best chance of detection is to:  Analyze regularly  Be familiar with the time, place and person characteristics of the diseases in your area Triggers

Objectives of an outbreak investigation 1.Verify 2.Recognize the magnitude 3.Diagnose the agent 4.Identify the source and mode of transmission 5.Formulate prevention and control measures Host EnvironmentAgent An outbreak comes from a change in the way the host, the environment and the agent interact: This interaction needs to be understood to propose recommendations Investigations

Working well with the laboratory Develop rapport with the laboratory Collect specimen according to the guidelines and access on-line resources if needed Protect the patient, yourself and others with biosafety You can contribute to quality assurance!

Investigating an outbreak

Steps of a full outbreak investigation using analytical epidemiology to identify the source of infection 1.Determine the existence of an outbreak 2.Confirm the diagnosis 3.Define a case 4.Search for cases 5.Generate hypotheses using descriptive findings Time, place and person information 6.Test hypotheses based upon an analytical study  Compare cases with non cases 7.Draw conclusions 8.Compare the hypothesis with established facts 9.Communicate findings 10.Execute prevention measures

Maximizing the chances that results of an investigation is used for action Appreciate the point of view of the manager  Don’t flag problems  Provide solutions Understand that your recommendations have implications for resources allocation Deliver useful recommendations Evidence based Specific Feasible Cost effective Acceptable Ethical Decision makers

Communicating results effectively Communicate WITH and not TO the audience Keep in mind what is needed out of people Pilot test communication material Have your oral presentations guided by a clear SOCO

The six “S” of technical writing 1.Simple 2.Short 3.Structured 4.Sequential 5.Strong 6.Specific The six “ S ”

Using high-level outlines to prepare a report Skeleton of the report in bullet points Outline of various sections  Spell out all titles  Use outline format of word processors  Summarize each paragraph with a bullet point List of tables and figures  Spell out titles Reach consensus on the outline Expand The six “ S ”

Always add summary to your reports The audience of your report may be too busy to read it completely Summary:  < one page  < 300 words Structure your summary with subheadings "I'm sorry to write you a long letter. I had no time to write a shorter one” Mark Twain The six “ S ”

Rationale for feedback of surveillance data Motivation Those who collected data see how they fit in the bigger picture Reliability Identifies errors Reactivity Places everyone on the same page Quality Increases transparency Education Demonstrates how the system works

Data flow and feedback: Level by level Centre State District Primary / Community health centre Data Feedback Community

Content of feedback Information on diseases under surveillance  Summary data tables  Analyzed epidemiological information Time (Graphs with trends) Place (Maps) Persons (Tables) Information on quality of data collected

Content of feedback Information on diseases under surveillance Information on quality of data collected  Regularity of reporting  Timeliness of reporting  Completeness of reporting  Responses initiated by the unit  Validity of data

Integrated disease surveillance programme activities to be monitored Collection and compilation of data Laboratory Analysis and interpretation Follow-up action Feedback Monitoring

The supervision visit Activities during the visit  Use checklist  Observe  Review records  Conduct focus group discussions with staff Provide feedback  Underline achievements  Mention opportunities for improvement Recommend actions with a time frame Supervision

Go back to your district and be an active District Surveillance officer Systematically, collect, transmit, analyze and feedback public health data for decision making Surveillance DataInformation Action Analysis Interpretation

Your assignment for the next two weeks Go back to your district Pick up one disease of public health interest Analyze the data by time, place and person Produce a report with:  1 page of text, with conclusions and recommendations  1 graph of incidence over time  1 map  1 table of incidence by age and sex Share locally and send us a copy within 2 weeks!  We will give you feedback! Use the data for action and make it a habit! Supervision