Chapter 7

Epidemiological Surveillance
 Objectives
At the end of this session you are able to:
• Define what a surveillance is
• Know and list types of surveillance
• Understand and explain for what purpose
surveillance is used
• Understand the status of disease surveillance
in Ethiopia
 Cont…
• Surveillance is a system of close observation
of all aspects of the occurrence and
distribution of a given disease through
systematic collection, tabulation, analysis,
and dissemination of all relevant data
pertaining to that disease.
 Cont…
• Epidemiologic surveillance is the systematic
collection, analysis, interpretation and
dissemination of health related data in an
ongoing basis.
• Provides information for action
• Can be conducted globally, regionally,
nationally and locally.
 Cont…
We monitor health events 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 on the need to reallocate resources or shift
policy
– 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 out the need for changes in preventive measures
 Cont…
• Surveillance can be justified for two additional
purposes:
1) To learn more about the natural history, clinical
spectrums, and epidemiology of a disease, and
2) To obtain baseline data which we can use to
assess the effectiveness of prevention and
control measures when they are developed and
implemented.
 Cont…
• Interpretation of surveillance data may also
provide the basis for:
– Generating hypotheses
– stimulating community health research,
– test hypotheses regarding the impact of exposures
on disease occurrence, and
– develop statistical models of diseases
 Cont…
• The followings are some key sources of surveillance
data, not all of which are available in every country:
– 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
– Laboratory test utilization and result reports
– Drug utilization records
 Cont…
– Adverse drug reaction reports
– Special surveys (e.g., research data, serologic
surveys)
– Police records (especially for injury, alcohol-
related crime)
– 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.
• Sentinel surveillance uses a pre-arranged
sample of reporting sources to report all cases
of one or more conditions.
 Cont…
• Particularly in developing countries, sentinel
surveillance provides a practical alternative to
population-based surveillance.
 Surveillance data source and analysis
• Surveillance systems based on secondary data
analysis can make productive use of data sets
collected for other purposes.
• Data collected for marketing surveys, patient
management records, police records, and
other information sources can be exploited as
sources of surveillance data.
• Have less quality and timeliness
 Cont…
• Surveillance data is first analyzed in terms of
time, place, and person.
• Data are analyzed as rates, rather than simply
the numbers of cases reported.
• A critical step before calculating rates is the
identification of the appropriate denominator.
• There is no single "threshold" above which
disease patterns are different enough from the
expected to warrant further investigation.
 Cont…
• 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 are usually analyzed by
graphing the occurrence of disease by year.
• Apparent increases should be treated as real
until proven otherwise.
 Evaluation of Surveillance
In justifying, designing or evaluating a surveillance
system, the following aspects of the system should be
assessed:
1) The importance of the health event under
surveillance to the public health
a) Incidence and prevalence
b) Severity (case-fatality or death-to-case ratio)
c) Mortality (overall and age-specific mortality rates, years
of potential life lost)
d) Health care costs
e) Potential for spread
f) Preventability
 Cont…
2) The objectives and operation of the system
a) The case definition of the health event
b) The population under surveillance
c) The time period for data collection (weekly, monthly,
annually)
d) What information is collected (what programs need?)
e) The reporting sources
f) How data are handled (transfers, delays,
confidentiality)?
g) How data are analyzed (by whom? frequency,
thoroughness)
h) How data are disseminated?
 Cont…
3) The usefulness of the system
a) Action taken to date as a result of the information
b) future or potential uses
4) Attributes or qualities of the surveillance system
a) Simplicity
b) Flexibility
• With changes in case definition or
• Funding, and
• To add new diseases
c) Acceptability
• Often judged by
– Proportion who report, and
– Completeness of forms
 Cont…
d) Sensitivity
• ability to detect events it is intended to detect
e) Predictive value positive
• Proportion of reported cases which truly are cases, or
• Of epidemics which are actual epidemics
f) Representativeness
• Extent to which one can generalize or draw conclusions
from surveillance data, such as for calculating rates
g) Timeliness
5)Cost or resource requirements for system
operation
Limitations of the Surveillance system
• Surveillance systems are never perfect.
– Understanding the limitations of surveillance data is
important to ensure correct interpretation.
– The most common limitations of surveillance systems
include:
1. Under reporting
• due to lack of knowledge of reporting requirements,
• negative attitudes toward reporting
2. Lack of representativeness of reported cases
• due to a bias toward reporting severe cases, or
• increased likelihood of reporting after publicity
3. Lack of timeliness
4. Inconsistency of case-definitions
 Cont…
• Most commonly, surveillance systems are strengthened
by:
– Improving awareness of practitioners,
– Simplification of the process of reporting,
– Frequent feedback to those reporting,
– Widening the “net” (for example, obtaining reports from
laboratories or schools, rather than relying on physicians), and
– Using active rather than passive surveillance
• Remember to “share the data, share the responsibility,
and share the credit”.
 Important Points
• Factors related with the selection of disease for
surveillance:
– Magnitude of the disease
– Feasibility of control measures
– Need for monitoring and evaluating the performance of a control
program
– Resource availability
• Activities in surveillance:
– Data collection and recording
– Reporting and notification
– Compilation, data analysis, and interpretation
– Dissemination of findings for action
 Cont…
• Conditions in which active surveillance is appropriate:
– For periodic evaluation of ongoing programs
E.g. COVID-19, HIV/AIDS, EPI...
– For programs which have time limit of operation
E.g. Small pox
– With the occurrence of unusual situations:
• When a new disease/event discovered
• When investigating a new mode of transmission
• When a high-risk period is recognized
• When a disease appears in a new geographic area or found to
affect a new subgroup of the population
• When previously eradicated disease reappear or low incidence
disease occur at a higher level of endemicity
Features of good surveillance system
• Uses a combination of passive and active
mechanisms to collect data.
– Emphasize the collection of minimum data in a simplest
possible way.
– To assure quality and enhance compliance make sure that
the data collected is useful for the workers who collect
the data.
• Timely reporting
• Timely and comprehensive action
– Action must be targeted towards both case detection and
treatment and as well as to the control of the disease.
• Strong laboratory services for accurate diagnosis
 Integrated Disease Surveillance and Response
(IDSR): Concept and Experience in Ethiopia
• 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 programs in order to initiate timely
response (intervention).
 Cont…
• IDSR initiative was launched by the WHO-AFRO
(Africa regional office for WHO) in the second
half of the 1990’s.
• Ethiopia has made good progress in IDSR
implementation.
• Adaptation of the national guidelines and training
modules for IDSR, training for professionals from
national to woreda level, and preparation and
distribution of relevant forms are completed.
 Cont…
• Disease control and prevention objectives are
successfully met when resources are
dedicated to improving the ability of health
systems
– to detect targeted diseases,
– obtain laboratory confirmation of epidemics, and
– use action thresholds at the woreda level in an
integrated fashion
 Cont…
• Improving communicable disease surveillance
and response through integrated disease
surveillance (IDSR) linking
– Community,
– Health facility,
– Woreda and
– National levels promotes rational use of resources
• Integration of the surveillance and response
activities offers a lot of advantages
 Cont…
• Integrated disease surveillance and response:
– Focuses at the woreda level,
• this is the lowest level in the health system with full-time
staff dedicated to all aspects of public health.
– Coordinates and streamline all surveillance activities
combining available resources (human, material,
finance …) from a single focal point at woreda level.
– Facilitate collaboration between surveillance focal
points at the woreda, regional and national levels and
epidemic response committees at each level in taking
appropriate and timely public health responses and
actively seek opportunities for combining resources.
 Cont…
• The overall objective of the IDSR is to
improve the ability of health workers to
detect and respond to priority communicable
diseases at the woreda level.
• Effective and timely decision-making based on
good evidence increases efficient utilization of
available resources for preventing and
controlling communicable diseases and
improving the health status of the population.
 Cont…
In order to achieve its objectives IDSR should seek to:
• Strengthen the capacity of woredas to conduct
effective surveillance activities
• Integrate multiple surveillance systems, so that
personnel and resources can be used more
efficiently and effectively
• Improve the use of information for decision making
• Improve the flow of surveillance information
between and within levels of the health system
 Cont…
• Improve laboratory capacity in identification
of pathogens and monitoring of drug
sensitivity
• Increase the involvement of health workers in
the surveillance system.
• Emphasize on community participation in
detection and response to public health
problems
• Strengthen the involvement of laboratory
personnel in epidemiological surveillance
 Globally and National Priority Diseases for
Surveillance

Priority disease criteria

• Have a high potential for causing epidemics
• Have been targeted for eradication or
elimination
• Have significant public health importance
(causing many illnesses and deaths)
• Can be effectively controlled and prevented
 Cont…
• Currently, there are twenty reportable priority
diseases or conditions in Ethiopia, which are
included in the IDSR system.
• These twenty priority diseases are further
classified into:
– Immediately, and
– weekly reportable diseases
 I. Immediately reportable diseases (report
within 30 minutes to higher authority)
• Acute flaccid paralysis (AFP)
• Anthrax
• Avian human influenza
• Cholera
• Dracunculiasis/ Guinea worm disease
• Measles
• Neonatal tetanus
• Pandemic influenza A (H1N1)
• Rabies
• Severe acute respiratory syndrome (SARS)
• Smallpox
• Viral haemorrhagic fever (VHF)
• Yellow fever
 II. Weekly reportable diseases
• Dysentery
• Malaria
• Malnutrition
• Meningitis
• Relapsing fever
• Typhoid fever
• Typhus
 Health emergencies or conditions to be reported immediately

• Clusters of respiratory illness (including upper or lower

respiratory tract infections and difficulty in breathing)
• Clusters of gastrointestinal illness (including vomiting,
diarrhoea, abdominal pain, or any other gastrointestinal
distress)
• Influenza-like symptoms and signs, such as fever, cough and
runny nose
• Clusters of symptoms or signs indicating the possibility of
meningitis (stiff neck, sensitivity to bright light, severe
headache, etc.)
• Clusters of rash-like symptoms
• Non-traumatic coma (unconsciousness which is not due to
an injury), or sudden death.