SURVEILLANCE SYSTEM

Dr. Pranil MS Pradhan MD

Department of Community Medicine
and Public Health, IOM
 CONTENTS

 Surveillance general principle

 Uses of surveillance
 Pre –requisite for surveillance
 Attributes of effective surveillance
system
 Key issues in designing a surveillance
system
 Active/passive/sentinel surveillance
 EWARS
 SURVEILLANCE
 Surveillance is the epidemiological tool
for study of disease as a dynamic process
involving the ecology, the organism, the
host,reservoir,vector and environment, as
well as the complex mechanism
concerned with the spread of infection
and the extent to which spread occurs
 CONTD…
 It is defined as “ongoing and systemic
collection, analysis and
interpretation of outcome-specific
data essential for the planning,
implementation and evaluation of public
health practices, closely integrated with
the timely dissemination of the data to
those who need to know”.
 The purpose of public health practice is
prevention and control of diseases.
 COND….
 Survey:-Making a single observation to
measure and record something.
 Surveillance-Making repeated standard
surveys so that changes can be detected
 Monitoring-Surveillance undertaken to
ensure that the formulated standard are
being maintained.
 CONT……
 Evaluation-It is the periodic assessment
of changes in the targeted
results(objectives) that can be attributed
to surveillance .

 Evaluation attempts to attributes

changes in outputs, outcomes and
impact(negative or positive)of the
surveillance system.
 USES OF SURVEILLANCE
 It enables a rapid response to be made
if the incidence shows an increase.
 It helps to assess the incidence and
prevalence of disease with their
morbidity and mortality ,so that the
magnitude of the problems and their
importance can be known.
 It helps to establish priorities and plan
preventive programmes.
 CONTD….
 It is essential for identifying high risk
groups.
 It helps understanding of local
epidemiological trends and patterns.
 It is useful in monitoring and impact
evaluation of control programme
against specific disease.
PRE-REQUISITES FOR EFFECTIVE
SURVEILLANCE
 Use of standard case definitions
 Ensuring regularity of the reports
 Action on the reports
 ATTRIBUTES OF AN EFFECTIVE
SURVEILLANCE SYSTEM
 Simplicity
 Flexibility
 Data quality
 Acceptability
 Sensitivity
 Representativeness
 Positive predictive value
 CONTD……
 Timeliness
 Stability
 Usefulness
 ANALYSE AND INTERPRET
SURVEILLANCE DATA
Analysis of surveillance data involves:
 Data characteristics(through various

sources and level of notification)

 Descriptive analysis, by time, place and

person
 Generating hypothesis
 KEY ISSUES IN DESIGNING A
SURVEILLANCE SYSTEM
1. Public health importance of the
disease-i.e mortality,morbidity,cost/socio-
economic impact and preventability.
2. Objectives-(SMART-Specific,Measurable
,Action oriented,Realistic,Time-bound)
3. Case definition-It should be standard
whenever possible, acceptable,
understandable and should have
appropriate diagnostic criteria based on
the level of the health system.
 CONTD….
 A case may be classified as ‘suspect
'when the diagnosis is made by a
paraprofessional, ‘probable when the
diagnosis is based on clinical diagnosis by
a professional and/or combined with
epidemiological evidence and confirmed
when the clinical diagnosis is sustained
by supporting laboratory diagnosis.
 Example of Standard Case
Definition
 DENGUE FEVER:
An acute febrile illness
of 2-7 days duration with 2 or more of the
following:
i.e.- Headache, Retro-orbital Pain,Myalgia,
Arthralgia,Rash(initially macular and
blanching, later mobiliform,
Haemorrhagic manifestation)
 CONT…..
 SUSPECTED: A case compatible with the
clinical description.
 PROBABLE: A case compatible with the
clinical description with one or more of the
following:
1)Support serology(reciprocal
haemagglutination –inhibition titre>1280
2)Comparable IgG EIA titre or
positive IgM antibody titre in late acute or
convalescent-phase serum specimens.
 CONT…
3)Occurrence at same location
and time as other confirmed case of
dengue fever.
 CONFIRMED-A case compatible with the
clinical presentation and laboratory
confirmed.
 COND….
4.Data indicators required-The measures used
to monitor a disease, for example number of
cases of malaria reported, rate-number of cases
of ARI in children under 5 years per 100,000
population per year, ratio-proportion of children
with ARI who die etc. To find out data indicator
following should be found out:
 COND….
 Data set required:-Variables needed,
numerator e.g.-number of cases and deaths,
denominator e.g.-population under surveillance,
live births.

 Data sources:-Primary care providers, screening

hospital and clinics,laboratories,registers,vital
registration and statistics and other
sources(community,survey etc)
 CONTD….

 Data collection-Tools such as forms and

formats; method of collection, and
mechanism for confidentiality of data.
 The method of data collection include:
 ACTIVE SURVEILLANCE
 It implies active efforts made by staff of
health services to seek out cases of
certain specific disease in the community
mainly through door to door survey.
 It also includes the purposeful gathering
of information from institutions and
health care providers.
 COND….
 For e.g.- in malaria eradication
programme health care staffs makes
house-to house visit to detect fever cases
and takes subsequent steps for diagnosis
and treatment
 It ensures totality in collection but is
expensive and entails deployment of
health staff for the purpose of seeking
out specific cases for instituting control
measures.
 PASSIVE SURVEILLANCE
 It is the routine reporting of the cases of
diseases reaching health care facilities for
treatment or service. No special effort is
made to find unsuspected disease incidents.

 Eg: Physician sees a patient, diagnoses

measles, and then initiates a case report by
contacting the local health department and
providing the details as required for a case of
measles. Here, the local health department
relies on the physician to report the case
 SENTINEL SURVEILLANCE
 It is defined as a reporting system based
on selected institutions or individuals that
provide regular, complete reports on one
or more target diseases occuring,ideally
in a defined catchment area.
 The word ‘sentinel’ means a ‘watch dog’
or a ‘senior guard'.
 COND…….
 The concept was operationalised under
Expanded programme on immunization
for some vaccine preventable diseases in
1980 and later extended to cover AIDS.
 The first sentinel surveillance site was
established in 1981and a large number of
sentinel surveillance sites are now
operating.
 Sentinel Surveillance
 ADVANTAGES:
1)Information of good quality is made
regularly.
2)The quality is good as experts make the
diagnosis.
3)The system is inexpensive as often
these centres are already collecting most
items of a data as routine activity
4)Useful for identifying trends of
transmission
 CONT…
5)The surveillance data can also be used
for generating epidemiological models.

DISADVANTAGES:
1)Being based on hospital data, it is
biased and cannot be expected to fully
reflect the behavior of diseases in the
community in which the centre is
situated.
 CONT…
2)Mild cases and atypical cases often
escapes notice.
3)Certain sections or families may not
utilize the facilities or may not have easy
access due to physical or financial
reason.
4)Population at risk is unknown and
incidence rate cannot be calculated.
5)Rural area are excluded from the
system.
 CRITERIA TO BE SATISFIED BY
SENTINEL SURVEILLANCE CENTRE
 Large attendance of the patients of
targeted disease
 Reasonably accurate diagnosis
 Recording and reporting facilities
 Willingness to submit regular reports
 Easy accessibility to general population
 Treatment facility not too expensive or
specialized to exclude certain patients.
 CONT…..
5)Action as an outcome of the system-
Public health intervention/change in
service
provision/survey/research/legislation/
regulation.
6)Feedback-Two way, critical for motivation,
periodic communication(periodic staff
meetings,newsletter,routine visits).
 CONTD….
7)Evaluation-To be done from time to time,
to assess-is the system useful? Has it
achieved the surveillance objectives?
 A good network of motivated people is

the most critical ingredient of an effective

surveillance system.
SURVEILLANCE
SYSTEM IN
NEPAL
 EARLY WARNING AND REPORT
SYSTEM
 EWARS is a hospital based sentinel
surveillance system

 Was started in NEPAL in September 1996

 It was designed to provide more timely

information to the decision makers to
facilitate early response
Basic elements of surveillance
that were cornerstone to
EWARS development

 A mechanism for hospital inpatient-ward-

based case detection.
 Laboratories for identifying and
characterizing microbes.
 Information systems.
 Response (information feedback and
mobilization for investigation and
control).
 OBJECTIVES
 To develop a comprehensive,
computerized database of infectious
diseases of public health importance.
 To monitor and describe trends of
infectious diseases through a sentinel
surveillance network of hospitals followed
by public health action and research.
 To receive early warning signals of
diseases under surveillance and to detect
outbreaks
 CONT…..
 To instigate a concerted approach to
outbreak preparedness, investigation and
response
 To disseminate data/information on
infectious diseases through an
appropriate feedback system
 REFERENCES
 Epidemiology and management for health
care for all, Third Edition by P.V.Sathe
 Park’s Textbook of Preventive and Social
Medicine by K.PARK
 Oxford Textbook of Public Health ,5th
Edition by Walter W.Holland,Roger Detels
and Gearge Knox
 Weekly epidemiological record by WHO,
No 36,2004,79,321-328
http://www.who.int/wer
 CONT….
 Assessment of Early Warning and Report
System in Nepal by David F. Pyle, Lalit M.
Nath , Badri Lall Shrestha,Asok Sharma,
Sushil Koirala,March 2004
 Weekly Epidemiological Bulletin
Epidemiology and Disease Control Division
Ministry of Health and Population, Nepal
 Vaccine Preventable Disease Service Bulletin,
WHO Volume 16,week 25 2012
 WHO Recommended Surveillance Standard,
second edition, WHO/CDC/CSR/ISR/99.2
THANKYOU