PUBLIC HEALTH SURVEILLANCE

By Mohammed Jihad (BSc, MPHE)

2022
 Learning objectives
At the end of this lecture, students should be able to:
• Define PHEM
• Define EW
• Define IDSR
• Define public health surveillance
• List the essential activities of surveillance
• List the desirable characteristics of well-conducted
surveillance activities
• Describe sources of data and data systems commonly
used for public health surveillance
 Public Health Emergency Management
(PHEM)
• PHEM is designed to ensure rapid detection of any
public health threats, preparedness related to
logistic and fund administration, and prompt
response to and recovery from various public
health emergencies.
• PHEM is the process of anticipating, preventing,
preparing for, detecting, responding to, controlling
and recovering from consequences of public health
threats in order that health and economic impacts
are minimized.
 PHEM…
This core process is comprised of four sub
processes which are:
• Early Warning, (EWS),
• Public Health Emergency Preparedness,
(PHEP),
• Response (PHER), and
• Recovery (PHER).
PHEM core process
 Early warning
• Is the identification of a public health threat by
closely and frequently monitoring identified
indicators and predicting the risk it poses on
the health of the public and the health system.
• Purpose: enable the provision of timely and
effective information to the public and to
responders, through identified institutions
that allow preparing for effective response or
taking action to avoid or reduce risk.
Public health early warning indicators:
• Conditions which, when they occur or change,
signal an increase in the risk of occurrence of a
particular threat to public health.
• These indicators are regularly monitored to
identify situations for which a public health
action may be needed.
Major indicators of early warning
• An increase in the number of cases beyond
expected
• Un explained morbidity and mortality,
• Malnutrition,
• Evidence of increase in zoonotic disease and/or
vectors,
• Environmental changes, contamination (air
pollution, water quality changes,
contamination),
 Major indicators…..
• Drought, flood, severe weather (metrological
information),
• Agricultural events such as reduced harvest,
occurrence of pests or diseases,
• Refugees, internally displaced people,
disruption of health services and infrastructure,
• Important industrial accidents; chemical spills
etc.
Components of early warning system
 Integrated disease surveillance and
response (IDSR)
• Integrated disease surveillance and response
(IDSR) is an approach adapted to strengthen
national disease surveillance systems by
coordinating and streamlining all surveillance
activities and ensuring timely provision of
surveillance data to all disease prevention and
control programmes in order to initiate timely
response (intervention).
 Surveillance
• Is the systematic collection, analysis,
interpretation and dissemination of health
data in an on going basis.
• Surveillance provides "information for action"
which can be used to investigate, prevent, and
control disease in communities.
 Purposes of Surveillance
We conduct surveillance for the following purposes:
• To detect sudden changes in disease occurrence and
distribution (determines the need for epidemic
investigation and control) and to ensure that
effective action to control the disease is being done.
• To follow secular (long-term) trends and patterns of
disease (alerts decision makers of the need to
reallocate resources or shift policy)
 Purposes of Surveillance…
• To identify changes in agents and host factors
(helps to assess the potential for future
disease occurrence)
• To detect changes in health care practices
(points up the need for changes in preventive
measures)
 Sources of surveillance data
• Census data
• Mortality reports (birth and death certificates, autopsy
reports)
• Morbidity reports (notifiable disease reports)
• Hospital data (discharge diagnoses, surgical logs, hospital
infection reports)
• Absenteeism records (school, workplace, compensation
claims)
• Epidemic reports
 Sources….
• Laboratory test utilization and result reports
• Drug utilization records
• Adverse drug reaction reports
• Special surveys (e.g., research data, serologic
surveys)
• Police records (especially for injury, alcohol-
related crime)
 Sources….
• Information on animal reservoirs and vectors
(e.g., for rabies, plague, Lyme disease)
• Environmental data (hazard surveillance,
water and food testing)
• Special surveillance systems (e.g., for injury
and occupational illness)
 Types of Surveillance
Passive surveillance
Is that in which health care providers send reports
based on a known set of rules and regulations.
Active surveillance
• Is that in which public health officials contact
providers to solicit reports of events or diseases.
• Such active surveillance is usually limited to specific
diseases over a limited period of time, such as after
a community exposure or during an epidemic.
 Types of Surveillance
Sentinel surveillance
• It uses a pre-arranged sample of reporting sources to report
all cases of one or more conditions. Usually the sample
sources are selected to be those most likely to see cases.
• Particularly in developing countries, sentinel surveillance
provides a practical alternative to population-based
surveillance.
• Under this strategy, health officials define homogenous
population subgroups and the regions to be sampled. They
then identify institutions that serve the population subgroups
of interest, and that can and will obtain data regarding the
condition of interest.
 Surveillance activities

• Detection
• Collection (Registration)
• Confirmation (epidemiological and laboratory
confirmation)
• Reporting (early warning)
• Analysis and interpretation (detecting
outbreaks, changes in disease patterns)
 Surveillance activities

• Response (preventive and control measures,

outbreak investigation, program adjustment,
changes in policy and planning)
• Feedback, Evaluation and monitoring
• Dissemination
Identifying Priority Diseases and Conditions
for Surveillance
• It is clear that surveillance could not be
carried out for all diseases and conditions.
• Therefore, priority should be given to those
diseases that are of interest at national and
international levels.
• In Ethiopia 20 diseases (13 are immediately
reportable whereas 7 are weekly reportable)
are selected to be included into the routine
surveillance.
Immediately Reportable Diseases Weekly Reportable Diseases
1. Acute Flaccid Paralysis (AFP) /
Polio 14. Dysentery
2. Anthrax 15. Malaria
3. Avian Human Influenza 16. Meningococcal Meningitis
4. Cholera 17. Relapsing fever
5. Dracunculiasis / Guinea worm
18. Severe Malnutrition
6. Measles
7. NNT 19. Typhoid fever
8. Pandemic Influenza A 20. Typhus
9. Rabies
10. Smallpox
11. SARS
12. VHF
13. Yellow fever
 According to drafts of (2021) revision PHEM Guideline
Immediately Weekly Monthly
1. Anthrax 19. Malaria 28. New HIV cases
2. Measles 20. Diarrhea with dehydration in children <5 years 29. Hypertension new cases

3. Human influenza caused by new subtype 21. Acute jaundice syndrome within 14 days of illness 30. Diabetes new cases

4. Adverse events following immunization (AEFI) 22. Severe pneumonia in children under 5 years age 31.Tuberculosis

5. Neonatal s/ non neonatal tetanus 23. Dysentery 32. Moderate Acute Malnutrition (MAM)

6. Rabies 24. Relapsing Fever

7. Smallpox 25. Meningitis
8. Severe Acute Respiratory Syndrome (SARS) 26. Severe Acute Malnutrition (SAM)
9. Yellow fever 27. Scabies
10. Poliomyelitis (acute flaccid paralysis)
11. Chikungunya
12. Viral Hemorrhagic Fever (VHF)
13. Cholera
14. Dracunculiasis (guinea worm)
15. Dengue fever
16. COVID-19
17. Maternal death
18. Perinatal death
Diseases and conditions selection criteria:

1. Diseases which have high epidemic potential

2. Required internationally under IHR2005
3. Diseases targeted for eradication or
elimination
4. Diseases which have a significant public health
importance
5. Diseases that have available effective control
and prevention measures for addressing the
public health problem they pose.
 Surveillance Data Analysis
• As with all descriptive epidemiologic data,
surveillance data is first analysed in terms of
time, place, and person.
• Data are analysed as rates, rather than simply
the numbers of cases reported. When delays
occur between diagnosis and reporting, we
analyse data by the date of onset, rather than
the date of the report.
 Surveillance Data Analysis
• A critical step before calculating rates is the
identification of the appropriate denominator.
• Simple tabular and graphic techniques are
used initially to display the data, although
sophisticated techniques such as cluster and
time series analysis and computer mapping
may also be used.
 Surveillance Data Analysis
• Surveillance data may be assessed for changes
over time by comparing the number of cases
for the current period with the number
reported for the same period in each of the
last three years.
• Secular trends, or long-term trends, are
usually analysed by graphing the occurrence
of disease by year.
 Surveillance Data Analysis
• The surveillance data should also be analysed by
place.
• Even when the secular trend reveals no increases
in overall incidence, analysis by place may reveal
a geographic cluster of cases which deserves
investigation.
• Analysing surveillance data by the characteristics
by person variables (age, sex, behavioural risk
factors) may also reveals patterns or clues.
 Surveillance Data Analysis
• There is no single "threshold" above which disease
patterns are different enough from the expected to
warrant further investigation.
• The excess necessary to trigger action may depend on
the priority assigned to the disease and the interests,
capabilities and resources of the ministry or agency.
• Public, political, or media attention and pressure,
however, can sometimes make it necessary to
investigate minor variations in disease occurrence
which might no otherwise be pursued.
 Evaluation of Surveillance
In justifying, designing or evaluating a surveillance
system, the following aspects of the system should be
assessed:
1) The importance to the public health of the health
event under surveillance
2) The objectives and operation of the system
3) The system’s usefulness
a) Action taken to date as a result of the information
b) future or potential uses
 Evaluation of Surveillance
4) Attributes or qualities of the surveillance system:
• Simplicity
• Flexibility (with changes in case definition or funding, to
add new diseases)
• Acceptability (often judged by proportion who report
completeness of forms)
• Sensitivity
• PPV (proportion of reported case, which truly are cases)
• Representativeness
• Timeliness
5) Resource used
 Features of good surveillance system
• Uses a combination of passive and active
mechanisms to collect data.
• Timely reporting.
• Timely and comprehensive action.
• Strong laboratory services for accurate
diagnosis.
 Limitations of Surveillance
1. Under reporting
2. Lack of representativeness of reported cases
3. Lack of timeliness
4. Inconsistency of case-definitions
SCREENING
 Population screening
• Is defined as the application of a test to
asymptomatic people to detect occult disease
or a precursor state (Screening in Chronic
Disease, Alan Morrison).
• The immediate objective is to classify them as
being likely or unlikely of having the disease
under investigation.

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 Population screening
• The goal is to reduce mortality and morbidity
on the basis of evidence that earlier
treatment improves patient outcomes.
• The design and evaluation of population
screening programs depend crucially on the
natural history of the disease in question.
• For a screening program to be successful it
must be directed at a suitable disease and
employ a good test.
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 Population screening…
• Diseases for which screening may be appropriate
are typically cancers of various sites, infectious
diseases with long latency periods such as HIV
and syphilis, and physiologic derangements or
metabolic disorders such as hypertension,
hypercholesterolemia, phenylketonuria, etc.
• What these conditions have in common is that
they have serious consequences which can be
alleviated if treatment is instituted early enough.

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Criteria for early detection of disease through screening

1. Natural history of disease must be

understood
2. Effective treatment is available
3. A test is available by which the disease can
be recognized in its pre-clinical phase
4. The application of screening makes better
use of limited resources than competing
medical activities

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 Measuring accuracy in classification and
detection
• In general, any deviation between the (often-
unknown) truly relevant biological entity and
the result of the system used to define and
detect or quantify it can be regarded as
measurement error.
• Sensitivity and specificity are the basic
measures used in epidemiology to quantify
accuracy of detection and classification
methods.
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 Measuring accuracy in classification and
detection
• These measures can be applied to the
detection of any entity, of course, whether it is
a disorder, an exposure, or any characteristic.
• Besides their use in epidemiology in general,
these measures are important for the
selection and interpretation of diagnostic tests
used in clinical practice.

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 Measuring accuracy in classification and
detection
• If a condition or characteristic can be present
or absent, then the accuracy of our system of
detection and labelling can be assessed by its
ability to detect the condition in those who
have it as well as by its ability to correctly
classify people in whom the condition is
absent.

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 The two basic measures of accuracy of
classification and detection
• Sensitivity – the proportion of persons who
have the condition who are correctly
identified as cases.
• Specificity – the proportion of people who do
not have the condition who are correctly
classified as non cases.

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 Table: 1 basic measures of accuracy of
classification
True status

+ -
+ a b a+b = (Positive test )
Classification
status
- c d c+d = (Negative test)

a+c b+d
Total (cases) (non cases)

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 basic measures…..
From table 1 above:
• Sensitivity (accuracy in classification of cases )
= a / (a + c)
• Specificity (accuracy in classification of non
cases ) = d / (b + d)

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 basic measures…..
• The following terms are used to refer to the four
cells of the above table 1:
• a = True positive, TP – people with the disease who
test positive
• b = False positive, FP – people without the disease
who test positive
• c = False negative, FN – people with the disease who
test negative
• d = True negative, TN – people without the disease
who test negative
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 basic measures…..
• However, these terms are somewhat ambiguous
(note that "positive" and "negative" refer to the
result of the test and not necessarily to the true
condition).
• The relative costs (financial and human) of false
negatives and false positives are key factors in
choosing between sensitivity and specificity when
a choice must be made. The more urgent is
detection of the condition, the greater the need
for sensitivity.
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 basic measures…..
• Thus, a condition that has severe consequences if
left untreated and which can be readily treated if
detected early implies the need for a test with
high sensitivity so that false negative minimized.
• A condition for which an expensive, invasive, and
painful diagnostic workup will follow the results
of a positive test implies the need for a test with
high specificity, to avoid false positive tests.

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 Predictive value
• The concept of predictive value is used to
assess the performance of a test in relation to
a given frequency of the condition being
sought.
• Predictive value is an essential measure for
assessing the effectiveness of a detection
procedure.

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 Predictive value
• The positive predictive value (PPV) is defined
as the proportion of people with the condition
among all those who received a positive test
result.
• Similarly, the negative predictive value is the
proportion of people without the condition
among all those who received a negative test
result. Using the same table as before:

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 Predictive value…
Using table 1 above, predictive value calculated
as follows
• Positive predictive value (PPV) = a / (a + b)
• Negative predictive value (NPV) = d / (c + d)

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 Predictive value…
• Also, since predictive value can be regarded as the
probability that a given test result has correctly
classified a patient, this concept is also fundamental
for interpreting a clinical measurement or diagnostic
test as well as the presence of signs or symptoms.
• The PPV provides an estimate of the probability that
someone with a positive result in fact has the condition
• The NPV provides an estimate that someone with a
negative result does not in fact have the condition.

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 Predictive value…
• In screening program in the general population,
the specificity will typically dominate.
• Even with perfect sensitivity, the number of true
cases cannot exceed the population size multiplied
by the prevalence, which is usually small.
• The number of false positives equals the false
positive rate (1–specificity) multiplied by the
number of no cases, which for a rare disease is
almost the same as the population size.

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 Predictive value…
• So unless the prevalence is greater than the
false positive rate, the majority of test
positives will not have the disease. For
example, if only 1% of the population has the
condition, then even if the specificity is 95%
(false positive rate of 5%) the group who
receive positive tests will consist primarily of
non cases:

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 Exercise 1

In a population of 10,000 people, the above numbers become

100 (1%) cases, all of whom are detected, and 9,900 non
cases, 595 of whom receive positive tests, for a total of 695
people receiving positive tests, 100 of whom have the
condition.
Calculate:
1. Sensitivity
2. Specificity
3. PVP
4. PVN
5. False positive
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 Table 2

Cases Non cases Total

+ 100 595 695

- 0 9305 9305

Total 100 9900 10000

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 Answers for Exercise 1
1. Sensitivity = a/(a+c)
100/100 = 100%
2. Specificity = d/(d+b) 9305/9900 = 94%
3. PPV = a/(a+b) = 100/695 = 14%
4. NPP = d/(c+d) = 9305/9305= 100%
5. False positive = 1- Specificity = 6%

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The End!