DISEASE

SURVEILLANCE
 Introduction
• Routinely collected data are often used to provide a rough indication of the
frequency of occurrence of disease and their descriptive epidemiology.
Such data can also serve to provide leads concerning disease aetiology.

• However, while some data are readily available, in that they are routinely
collected, for some disorders no routinely collected source of data exists,
and thus the investigator must undertake a study to obtain basic
information. The two systems form a surveillance system.

• Any surveillance system must be action oriented. Information coming out

of a surveillance system must be able to stimulate action.
Definition:
• Surveillance is defined as the systematic collection of
data pertaining to the occurrence of specific diseases,
the analysis and interpretation of the data, and the
dissemination of consolidated and processed
information to contributors to the program and other
interested parties.
Importance of disease surveillance in public health.
Surveillance is a primary function of public health and has numerous uses,
including:
• Estimating the magnitude of a health problem
• Determining the geographic distribution of illness
• Characterizing the natural history of disease
• Detecting epidemics / define a problem
• Generating hypothesis – stimulate research
• Evaluating control measures
• Monitoring changes in infectious agents
• Detecting changes in health practice
• Facilitating planning
These uses are reflected in the six objectives of
public health surveillance, which are to:
• Systematically monitor trends in health, disease and the determinants
of health.
• Rapidly detect unusual events, epidemics or other changes in the
health or determinants of health of a population.
• Evaluate new or ongoing prevention control measures.
• Plan and set priorities for health policies and programs.
• Suggest hypotheses concerning the determinants of health in
populations.
• Inform individuals and communities, enabling them to take action to
protect and improve their individual and community health.
Attributes of a surveillance system:

• Simplicity of the system structure and operation.

• Flexibility to look at new questions posed by research and accommodate
changes in technology or reporting definitions.
• Data quality for complete and valid data.
• Acceptability to generate enthusiasm and willingness to participate in the
system.
• Sensitivity for capturing all events and monitoring trends
• Predictive value positive of capturing true cases.
• Representativeness of the information for individuals in the United States
• Timeliness of process from collecting information to delivering it to make health
care changes.
• Stability to reliably operate and provide information when called upon.
Types of disease surveillance
• Although the surveillance cycle is consistent across a range of
disease and conditions, the specific methods can vary, depending
on conditions under surveillance, required coverage, timeliness,
and available resources.
• The following section outlines some of the methods and
approaches used in public health surveillance. 
• Surveillance can be passive or active, depending on the way the
data is collected.
Passive Surveillance
• Passive surveillance forms the bulk of disease
surveillance system.
• In most cases, routinely collected data provides the
data for monitoring morbidity and mortality trends
and are incorporated under the term surveillance.
• Passive surveillance involves passive reporting of
occurrence of diseases of interest. The report can be
by health units, laboratories, employers, school
authorities etc.
• Reporting is usually done using prescribed forms.
Ctn.
• Due to the passive way in which the system runs, passive surveillance
is usually associated with some challenges namely:-
• Under reporting
• Incomplete reporting
• Inaccurate reporting
• Multiple reporting of one event
• Lack of data analysis and therefore no utilisation of data.
• Information on some diseases may not be collected on routine
basis.
Passive surveillance of however cheaper than active surveillance
and involves a wider group people
Active surveillance

• An active surveillance system provides stimulus to health care

workers in the form of individual feedback or other incentives.
• Often reporting frequency by individual health workers is monitored;
health workers who consistently fail to report or complete the forms
incorrectly are provided specific feedback to improve their
performance. There may also be incentives provided for complete
reporting.
• Active surveillance requires substantially more time and resources
and is therefore less commonly used in emergencies. But it is often
more complete than passive surveillance.
Ctd.
• It is often used if an outbreak has begun or is suspected to keep
close track of the number of cases.
• Community health workers may be asked to do active case finding
in the community in order to detect those patients who may not
come to health facilities for treatment.
• For active surveillance, criteria are established for reporting disease
(or its absence), risk factors or health events, but those maintaining
the surveillance system initiate reporting.
• Active surveillance is used when there is an indication that
something unusual is occurring.
Ctd.
• For example - if a health department receives a case report for
measles, a serious vaccine-preventable disease, active surveillance
will be triggered.
• Public health practitioners will actively search for other cases, using a
standard case definition: calling doctors' offices for any cases,
following up to find additional cases among those exposed, checking
laboratories.
• Active surveillance can also take the form of regular outreach to
identified personnel, to stimulate the reporting of specific diseases or
injuries.
Sentinel surveillance

• Instead of attempting to gather surveillance data from all health care

workers, a sentinel surveillance system selects, either randomly or
intentionally, a small group of health workers from whom to gather
data.
• These health workers then receive greater attention from health
authorities than would be possible with universal surveillance.
• Sentinel surveillance also requires more time and resources, but can
often produce more detailed data on cases of illness because the
health care workers have agreed to participate and may receive
incentives.
Ctd.
• It may be the best type of surveillance if more
intensive investigation of each case is necessary to
collect the necessary data.
• For example, sentinel influenza surveillance in the
United States collects nasopharyngeal swabs from
each patient at selected sites to identify the type of
influenza virus.
• Collection of such data from all health workers would
not be possible.
Ctd.
• Sentinel surveillance may include the following:-
• Designing special forms that are different from the routinely
used forms.
• Identification of specific personnel to be responsible for active
surveillance.
• Conducting special training of personnel involved.
• Provision of special equipment to increase accuracy of case
identification.
• Identifying only some centres to participate in active
surveillance
• Provision of some incentives to personnel
Sources of data for surveillance
• Mortality registration
• Morbidity registration
• Epidemic reporting
• Laboratory investigation
• Surveys
• Individual case investigation
• Population and environment information.
• Epidemic field investigations.
• Hospital records
• Media reports
• Etc.
Core Steps in a Surveillance System
Design of a comprehensive surveillance system includes several core steps
that carefully weigh the desirable attributes of a surveillance system.
• The first step includes the selection of important topics and measures
within each topic area.
• The second includes establishment of indicators for each measure, along
with selection of possible data sources.
• Third, data are collected or assembled from sources and integrated if
obtained from more than one data source.
• Fourth, data are analyzed to address each indicator of interest.
• Fifth, results are interpreted and assembled for presentation.
• Finally, the products of the surveillance system are disseminated.
Ctd.
Model of the Cycle of Surveillance
The Outbreak Investigation Process

Outbreak Investigation Team

• If an outbreak is suspected an Outbreak Control Team (OCT) should
be convened to conduct the investigation with the following
represented in the membership;
• Consultant in Communicable Disease Control (CCDC)/Consultant in
Health Protection (CHP)
• Environmental Health Officer (EHO)
• Consultant Microbiologist or Virologist
• Secretarial/Administrative support
With consideration of:

• Epidemiologist
• Media/press officer
• Infection control nurse
• State veterinary service
• Food chemist/microbiologist/Food Standards Authority
• Toxicologist
• Director of Public Health
• Water company
• ETC.
Steps:
1.    Confirmation of Outbreak
• Is there an increase in the number of cases expected in the
population/time/place?
• Confirm numbers; interview cases, review laboratory findings
• Is further investigation needed? 
• The extent and urgency of the investigation should be considered.
 
2.    Verify Diagnosis
• Obtain medical records and laboratory reports
• Repeat tests if necessary
• Further clinical testing if needed
 
3. Case definition
Component of case definition Example) Hepatitis A Outbreak
(
 

Person   Type of illness (e.g. “a person

‘A person with an acute illness
with…”)
Place     Location of suspected exposure which occurred after staying at Hotel X
Time      Based on incubation (if known)   between Sep-Nov 2015
with jaundice or elevated liver function
Clinical symptoms/Lab results
tests
of all residents and diners during this
Define population at risk
period.’
4.    Case Finding

• Interview known cases

• Locate others exposed to probable risk factor
• Review routine surveillance data, notifications and
laboratory results
• Contact other CCDC’s/CHPs, EHO’s, health workers
 
5.    Descriptive Epidemiology

Using data collected it can be arranged by person/place/time into

descriptive epidemiology.
• Epidemic Curve
• Graph of occurrences of cases over time, this can help determine the
nature of the outbreak:
point (common) source
• propagated (continuing) source
• point source and person to person spread
Line List
• A table summarising the information about persons
associated with the outbreak.
• Each row represents a single individual and each column
represents a specific characteristic:
• identifying information
• demographics
• dates of illness/results
• pertinent risk factors
• exposures
• clinical details/lab results
6.    Generate Hypothesis

• Causes may have already been suspected, however, a formal

hypothesis is helpful to establish after reflecting on the data
interpreted in the descriptive epidemiology.  It is useful for
determining the most likely exposure that has caused the
outbreak.
• Microbiological results of food/food/environmental samples
(EHO to visit site)
• Veterinary investigation if appropriate.
 
7. Analytical Epidemiology

• Useful to conduct analytical studies to test the hypothesis.  If controls

chosen appropriately this will reduce the bias in the studies performed.
• Assess exposures consistently between cases and controls (ill and non-
ill).
Cohort Study
• Everyone potentially exposed
• Only use if a comprehensive list available
• RELATIVE RISK & ATTACK RATE= measure of association
e.g. Food based source outbreak at a wedding; guest list known,
Ctd.

Case Control Study

• Comparison of exposure amongst cases and controls.
• Useful study if complete list unavailable or is too large
• ODDS RATIO = measure of association, e.g. restaurant outbreak
 
8.    Evaluate Control Measures
• Monitor incidence of cases once control measures enforced.
• Laboratory results useful for continued definitive identification of
infectious agent in cases and if appropriate monitoring response to
treatment/control measures.
 
Ctd.
• 9.    Surveillance
• Documenting the effectiveness of control measures.
• Enhanced surveillance through laboratories and healthcare providers.

• Control Measures
• Immediate control measures may be indicated from the start of the
outbreak.
• Guided by epidemiological results and environmental investigation.
Ctd.
Control source
• Animal/Human/Environmental
• Consider closing outlet
• Isolate and/or treat cases
• Destroy/treat food
• EHO to take samples if necessary
Protect persons at risk
• Consider prophylaxis (e.g. antibiotics)
• Improve hygiene / personal protective equipment if applicable
Interrupting transmission
• Depends on the mode of spread (e.g. bottled water if contaminated
water supply with Cryptosporidium). 
Communication
• During outbreak
• Agree media strategy at initial OCT meeting and review at every
meeting
• Information to the public and health professionals
 
Ctd.

After outbreak
• Outbreak report published and disseminated
• Recommendations made
 
Media Strategy
• Ensure accurate and timely information relayed
• Consider which type of media and for which groups; social
media/secure communications/sensitive information/anonymity of
cases.
• Media attention may be necessary if public action is required. 
conclusion
• Disease surveillance is very important in the
prevention and control of communicable diseases.
• To be effective, any surveillance system should be
action-oriented. That is, any data collection system
can only be useful if data collected is analysed and
information from it utilized.
• It should also be pointed out that a good feed back
mechanism is desirable for every surveillance system.