1. Feedback
Integrated Disease Surveillance Programme (IDSP) district surveillance officers (DSO) course

2. Preliminary questions to the group
Were you already involved in feedback of surveillance data?
If yes, what difficulties did you face?
What would you like to learn about feedback of surveillance data?
The usual warm up… 2

3. Warm up exercise Diphtheria persists in Delhi
One hospital used at a sentinel centre
Data analyzed from
A warming up exercise. 3

4. Diphtheria incidence and case fatality, sentinel unit, New Delhi, India, 1954-97
1800
40%
1600
Cases
35%
Case fatality
1400
30%
1200
25%
1000
Number of cases
Case fatality
20%
Examine this set of data about Diphtheria in Delhi.
Describe before you interpret.
800
15%
600
10%
400
200 5% 0%
1954
1956
1958
1960
1962
1964 4
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
Year

5. Diphtheria incidence by month, sentinel unit, New Delhi, India, 199735
Cases 30
Deaths 25 20
Number of cases
More on seasonality. 15 10 5 5 J F M A M J J A S O N D
Month

6. Characteristics of diphtheria cases, sentinel unit, New Delhi, India, 1997
% Total
Death
CFR (%)
Age
<1 20 14 10 50
1-4 73 51 22 30
5-9 38 27 13 34
10+ 12 8
Sex
Male 90 63
Female 53 37 18
Religion
Hindu 89 62 25 28
Muslim * 54
Vaccine
Yes 15 1 7 No
114 80 43 ?
Total
143
100 45 31
Characteristics of the persons affected.
* Account for 9%, 17% ad 5% of the population in Delhi, UP and Haryana 6

7. Questions for the group: Propose messages for feedback
Describe what you see
Recommend action to report in your feedback bulletin
Summarize the data.
Propose interpretations.
What would you report in a feedback bulletin? 7

8. Key findings messages re: diphtheria in Delhi, India,1997
Incidence decreases
Case fatality increased
Seasonality:
August to October
Most cases among unvaccinated, at at age when they should be protected from primary vaccination
The solution. 8

9. Key recommendations re: diphtheria in Delhi, India,1997
Increase vaccine coverage and reach unvaccinated pockets
Store and use anti-toxin early
Recommendations. 9

10. Group exercise to conclude
Outline of the session
Rationale for feedback
Content of feedback
Feedback mechanisms
Group exercise to conclude
Outline of the session. 10

11. Difficulties with surveillance system with no feedback
Lack of motivation
Data disappear in a black hole
Unreliability
Mistakes are not corrected
Sluggishness
The various levels do not communicate
Data falsification
The data is opaque
Weak human resources
The actors do not see the system in action
These are the consequences of a surveillance system with no feedback.
Self explanatory. 11

12. Rationale for feedback of surveillance data
Motivation
Everyone sees how their data fit in the bigger picture
Reliability
Identifies errors
Reactivity
Places everyone on the same page
Quality
Increases transparency
Education
Demonstrates how the system works
So we need to have a feedback, with its advantages.
See how the advantages parallel the problems in the previous slide. 12

13. A dynamic vision of surveillance
Collect and transmit data
Make decisions
All levels use information to make decisions
Feedback information
Analyze data
Feedback closes the loop and brings life to the system. 13
Surveillance

14. Data flow and feedback: Level by level
Centre
State
Data
District
Feedback
Feedback must go down the system in the same way that the data comes up.
Primary / Community health centre
Community 14

15. Content of feedback Information on diseases under surveillance
Information on quality of data collected
Feedback must contain two types of information:
Data on the diseases themselves
Information on the quality of the data 15

16. 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
An expansion of the first point.
Again, recurrence of the time, place and persons aspects: That is the information that needs to be feedback. 16

17. 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
An expansion of the second point.
A list of the points that will reflect data quality. 17

18. Feedback methods Newsletters, bulleting Monthly review meetings
Outbreak investigation reports
Informal feedback
Electronic communication
Feedback can use various methods (media) 18

19. Newsletter Regular epidemiological bulletin Educational tool Contains
Summary tables and graphs
Commentary on diseases or topic
One of them is the newsletter. 19

20. Monthly review meetings
District / block monthly meeting
Presentation of data during meetings
Generates comments from peers
Need to stress positive aspects
Public negative comments may de-motivate
Monthly meeting are an opportunity to get feedback.
But that feedback needs to have some consistence: Some real data. 20

21. Outbreak investigation reports
Excellent for feedback and learning
Allow sharing of experiences that may be encountered in other places
Content
Information about the epidemiological characteristics of disease
Lessons learned in the investigation process
Outbreak investigation reports are excellent for feedback.
They demonstrate the usefulness of the system.
They provide information about disease patterns.
They disseminate outbreak investigation methods. 21

22. Informal feedback Oral feedback Useful for pointing out mistakes
Does not suffice by itself
Informal feedback is fine but not sufficient. 22

23. Electronic methods Through email, websites Fast and efficient
May be updated rapidly
Allows
Dynamic data presentation
Queries
Electronic methods may be faster, more dynamic and interactive. 23

24. Take home messages Feedback closes the surveillance loop Feedback
Epidemiological information
Time
Place
Person
Information on data quality
Use all possible mechanisms of feedback to get the information across
The take home messages of the session. 24

25. Exercise
Read the article on the analysis of measles surveillance data in Uttar Pradesh in 1996
Singh J. et al. Widespread outbreaks of measles in rural Uttar Pradesh, India, 1996: High risk areas and groups. Indian Pediatrics 1999; 36:
Imagine you need to prepare a feedback meeting with health officials in Uttar Pradesh
You need to prepare a presentation
Now an exercise.
Obtain that article on measles in Uttar Pradesh.
This article is made of a secondary analysis of surveillance data.
Imagine you need to provide feedback to health officials in UP. 25

26. Group work Sit down by by groups of 4 or 5
Extract information from the article to structure your feedback
Use a table format to prepare your presentation
Organize for some group work. 26

27. Empty table shell to organize feedback information
Findings
Interpretation
Recommendations
Epi data
Time …
Place
Person
Data quality issues
Surveillance issues
Each group should use this empty table shell and see how the time, place and person information can be used for recommendations. For each element (time, place and person), extract:
The finding
Its interpretation (the conclusion)
The recommendation to offer
Note your feedback also needs to include some points on data quality.
You can make 4 groups for time, place, person and data quality. 27

28. Break in groups
Take 15 minutes
Now on to the group work.

29. Key elements of feedback for measles in Uttar Pradesh, India, 1996
Findings
Interpretation
Recommendations
Epi data
Time
Most cases in low transmission months
Measles all year long
Be mobilized all year long
Place
Deaths concentrates in 10 districts
Higher incidence?
Better reporting?
Compare reporting practices in the 10 districts with the others
Person
85% cases not vaccinated
Measles persists because of low vaccine coverage
Increase coverage
Efficacy 92%
Vaccine works in UP
Data quality issues
Surveillance
1% of estimated cases reported
Measles surveillance is weak
Improve reporting
This is a template of response. 29

30. Presenting your feedback
Present the background
Explain how you collected the data
Display the key results presented in the summary table
Back up data with tables, graphs and maps
Interpret the data
Summarize the recommendations that can be deducted from the data
This summarizes the method you could use to extract the information, interpret it and propose recommendations when preparing some feedback. 30

31. Additional reading
Section 4 of IDSP operations manual (Report 2-7, page 57-64)
Section 10 of IDSP operations manual
Module 10 of training manual
Additional reading. 31