1. 1 Lecture 5 Introduction to surveillance Definitions of surveillance Objectives of surveillance Public health vs health care surveillance Elements of a surveillance system Surveillance methods Cross-sectional and longitudinal approaches Sources of bias

2. 2 Definition of surveillance (Last, Dictionary of Epidemiology. 2001) 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. (Source: WHO)

3. 3 Definition of surveillance (Last, Dictionary of Epidemiology. 2001) Ongoing systematic collection, analysis, and interpretation of health data, essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.

4. 4 Definition of surveillance (Last, Dictionary of Epidemiology. 2001) Continuous analysis, interpretation, and feedback of systematically collected health data, generally using methods distinguished by their practicality, uniformity, and rapidity rather than by accuracy or completeness.

5. 5 Objectives of surveillance Related to particular population Links to services –disease control –results lead to action (e.g., case or outbreak investigation, contact tracing, interventions) Data for planning of services –identification of high-risk groups –projection of future service needs

6. 6 Objectives of surveillance (cont’d) Data for evaluation of services Links to research (research is not primary objective) –development of hypotheses

7. 7 Types/Sources of data Morbidity and mortality reports Laboratory diagnoses Outbreak reports Vaccine utilization Sickness absence Disease determinants (e.g., reservoirs of disease) Susceptibility measures (e.g., serological surveillance) And many others!

8. 8 Examples of surveillance Communicable diseases Health behaviors: –Drug use, risky sexual behavior –Risk factors for chronic diseases (e.g. smoking) Environmental risks and diseases Health care

9. 9 Public health vs health care surveillance Public health –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)

10. 10 Public health vs health care surveillance (cont’d) Health care surveillance –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

11. 11 Objectives of surveillance of health care Related to particular population –e.g., catchment population, patients, clients Monitoring of various aspects of health care –Safety (e.g., medical errors) –Efficiency (e.g., length of stay) –Professional practices (e.g., adherence to guidelines) –Acceptability (e.g., satisfaction with services) –Equity (e.g. access)

12. 12 Health care surveillance and quality improvement Quality management/assurance programs –system for maintaining/improving service Quality assessment/audit –measurement aspects: surveillance (incl. monitoring & surveys) Quality improvement –organized efforts to apply results of surveillance to improved services Linked through “Quality Cycle”

13. 13

14. 14 Elements of a surveillance system Case definition Indicators Population under surveillance Cycle of surveillance Confidentiality Incentives to participation

15. 15 Elements of surveillance system: case definition Requirements –Indicator (not diagnostic) of trends –Simple –Feasible –Reliable –Inexpensive

16. 16 Elements of surveillance system: case definition 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

17. 17 Case definition for AIDS (US) Original surveillance definition: –List of opportunistic infections or cancers without other cause 1985 revision –inclusion of positive HIV test result –additional conditions 1987 revision –more conditions (extrapulmonary TB) 1993 revision

18. 18 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

19. 19 Elements of surveillance system: cycle of surveillance Occurrence of health event Detection by health care provider Notification of health agency Analysis and interpretation Dissemination

20. 20 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

21. 21 Surveillance methods Active vs passive methods Legally notifiable diseases Sentinel events Sentinel surveillance Cross-sectional vs longitudinal

22. 22 Active vs passive surveillance Passive surveillance –Issue case definition –Wait for cases to be reported Active surveillance –Go looking for cases –E.g., MD offices, hospitals, pathology departments

23. 23 Surveillance of toxic shock syndrome

24. 24 TSS: passive surveillance

25. 25 TSS: active surveillance

26. 26 Surveillance methods: notifiable diseases Universally reportable: –internationally quarantinable diseases:plague, cholera, yellow fever, smallpox –under WHO surveillance: e.g., influenza, malaria Regularly required: –e.g., typhoid, diphtheria Others (vary by country, location): –Selectively required –Outbreaks of public health importance

27. 27 Surveillance methods: sentinel events Sentinel health event: –condition that can be used to assess the stability or change in health levels of a population –e.g., death from acute head injury a sentinel event for severe traffic injury death or severe health effect resulting from wrong medication, route or dose is a sentinel event for medication errors

28. 28 Surveillance methods: Sentinel surveillance Surveillance based on sub-populations (sentinel populations) selected to represent the relevant experience of entire population, e.g., –networks of family physicians –schools –worksites –volunteer sites

29. 29 Surveillance methods: volunteer providers Example: Worcester AIDS consortium HIV surveillance in Worcester, MA HIV related to drug injection a major focus Consortium members –drug treatment agencies –community health centers –health department clinics –county jail

30. 30 Worcester AIDS Consortium Voluntary HIV testing Standard risk assessment questionnaire Confidential data linkage Results: –differences in risk behaviour and HIV seroprevalence between treatment and non- treatment sites

31. 31 HIV risk factor surveillance

32. 32 WAC: HIV seroprevalence among male IDUs Sitetestself-report Drug treatment: –therapeutic community0%6% –detoxification9%15% –outpatient29%24% Non-drug treatment –health centers21%22% –jail23%23%

33. 33 Surveillance methods: longitudinal vs cross-sectional Longitudinal –Ongoing data collection –Incident cases –Examples: notifiable diseases, vital statistics, disease registries Cross-sectional –Serial surveys

34. 34 Mortality surveillance

35. 35 Measles surveillance

36. 36 Surveillance methods: surveys Examples: –National Population Health Survey –Sante Quebec Content: –Conditions, behaviours not easy to monitor routinely (mental health problems, smoking, use of complementary/alternative therapies)

37. 37 Sources of bias in surveillance systems Information bias: –Incomplete reporting (e.g., passive vs active surveillance) –Differences/changes in case definition Selection bias: –Non-representative sentinel populations –Non-representative survey samples

38. 38 Checks on completeness of reporting Alternative methods to identify reportable cases –death certificates –hospital discharge records –disease registries –medication records –pathologist records –MD offices

39. 39 Influenza: morbidity surveillance

40. 40 Influenza: mortality surveillance

41. 41 Influenza: laboratory surveillance

42. 42 Influenza: laboratory surveillance

43. 43 Mortality: effect of ICD revisions