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

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

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

6. 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

7. 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

8. 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

9. “Surveillance”

10. 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.

11. 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.

12. 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)

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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)

19. 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

20. 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)

21. 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

22. 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!

23. 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 !!!!

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

25. 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

26. 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

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

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

29. 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.

30. 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

31. 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).

32. 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

33. 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.

34. 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.

35. 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.

36. 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”

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

38. 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

39. 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

40. 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

41. 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

42. 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.

43. 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

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

45. 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

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

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

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

49. 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

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

51. 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. 

52. 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.

53. 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).

54. 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

55. 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.

56. 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?

57. 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?

58. Reporting Channels

59. 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

60. 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.

61. 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.

62. 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

63. 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)

64. 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)

65. 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?

66. 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

67. 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

68. 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

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

70. 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.

71. Key Indicators Absolute numbers Proportions Rates Percentages
Threshold

72. Information Management

73. Evaluation of Surveillance Systems

74. 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

75. 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

76. 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)

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

78. Mortality surveillance

79. Influenza: laboratory surveillance

80. Evaluate control measures of MEASLES
United States, 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
1963
1968
1973
1978
1983
1988
1993
1998
Year

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

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

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

85. 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, 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, 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, Published April 30, 2004, for MMWR 2002;51(No. 53): p.
59.

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

87. Remember…. Surveillance is information for action!