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  1. 1. Surveillance<br />Dr. Akhilesh BhargavaMD, DHA, PGDHRMProf. Community Medicine &Director-SIHFW, Jaipur<br />
  2. 2. Public Health Approach<br />Implementation:<br />How do you<br />do it?<br />Intervention<br />Evaluation:<br />What<br />works?<br />Risk Factor<br />Identification:<br />What is the <br />cause?<br />Surveillance:<br />What <br />is the <br />problem?<br />Response<br />Problem<br />Akhilesh Bhargava<br />2<br />
  3. 3. Surveillance<br />Information for Action<br />Surveillance is the bridge between what we think is happening and What actually is happening<br />Akhilesh Bhargava<br />3<br />
  4. 4. Surveillance ?<br /> “a system of close, continuousobservation of all aspects of the <br /> occurrence & distribution of a disease through systematic <br /> Collection,<br /> Tabulation,<br /> Analysis and <br /> Dissemination (Timely) of all relevant <br /> data pertaining to that Disease/event”. <br /> Descriptive (purposeful)<br />Action (Public health policy)<br />Akhilesh Bhargava<br />4<br />
  5. 5. Purpose:<br />General-<br /> Reducing mortality/ morbidity through timely prevention & control<br /> Specific-<br /><ul><li>Understanding problem </li></ul> NHD, Magnitude, <br /> Trend<br /><ul><li>Define priorities
  6. 6. Decide objectives
  7. 7. Determine strategies
  8. 8. Evaluate control/ prevention
  9. 9. Suggest further research</li></ul>Akhilesh Bhargava<br />5<br />
  10. 10. Surveillance helps in:<br />Understanding Natural History<br />Deciding levels of existence of disease<br />Explaining changes in pattern with time<br />Identifying Changes in agent characteristics<br />Measuring efficacy of control measure<br />Forecasting trends<br />Akhilesh Bhargava<br />6<br />
  11. 11. Uses of Public Health Surveillance<br />Estimate magnitude of the problem<br />Determine geographic distribution of illness<br />Portray the natural history of a disease<br />Detect epidemics/define a problem<br />Generate hypotheses, stimulate research<br />Evaluate control measures<br />Monitor changes in infectious agents<br />Detect changes in health practices<br />Facilitate planning<br />Akhilesh Bhargava<br />7<br />
  12. 12. Types:<br /><ul><li>Routine
  13. 13. Active (agency solicited)
  14. 14. Passive (provider initiated)
  15. 15. Sentinel
  16. 16. Reporting by specified units from defined area
  17. 17. Denominator absent
  18. 18. Focused (Situation / Process / Area)
  19. 19. Case/outbreak investigations
  20. 20. Special surveys-Nutritional surveillance </li></ul>Akhilesh Bhargava<br />8<br />
  21. 21. Routine surveillance<br />Through Out Patient Dept. of Health facilities (Passive) Wait & See who reports what<br />Field surveys (Active) Go & Get Data/ Information<br /> Issues-<br /> Representative?<br /> Home treatment?<br /> Number of Health Facilities reporting<br /> Completeness of reporting<br />Akhilesh Bhargava<br />9<br />
  22. 22. Passive<br />Simple<br />Less burdensome<br />Inexpensive<br />May not be representative<br />May fail to identify outbreaks<br />Akhilesh Bhargava<br />10<br />
  23. 23. Active<br />Assures complete reporting<br />Can be used with specific investigations<br />Can be done for brief periods<br />Requires skilled personnel<br />May be perceived as invasive<br />Expensive<br />Akhilesh Bhargava<br />11<br />
  24. 24. Sentinel Surveillance<br /> Monitoring of key health events through sentinel:<br />Sites<br />Events<br />Providers<br />Vectors/animals<br />Akhilesh Bhargava<br />12<br />
  25. 25. Sentinel surveillance<br />Reporting of health events by selected Units/ Professionals representing a geographic area<br />Could be active or Passive<br />Only a small number of units selected<br />Selected units report all cases for a specific time period<br />Reports include additional information<br />Easier to maintain Quality & Regularity<br />Denominator absent<br />Data collected are Not representative &<br /> NO generalization<br />Akhilesh Bhargava<br />13<br />
  26. 26. Good Surveillance system: <br /><ul><li>Simplicity-</li></ul> ease of operation- minimum paper work<br /> simple definitions<br /> using existing system<br /><ul><li> Flexibility
  27. 27. Acceptability
  28. 28. Sensitivity
  29. 29. Predictive value
  30. 30. Representative
  31. 31. Timeliness
  32. 32. Regularity
  33. 33. Data quality-complete/reliable/accurate
  34. 34. Cost-effectiveness</li></ul>Akhilesh Bhargava<br />14<br />
  35. 35. Initiating a Surveillance systemActivities:<br />Choose a disease that has proved control measures available<br />Define how data collected shall be used<br />Set a standard case definition<br />Use existing system<br />Visit those who supply Data<br />Develop a data base<br />Develop a regular reporting system for distribution (Feed back)<br />Akhilesh Bhargava<br />15<br />
  36. 36. Disease selection for surveillanceEligibility criteria:<br /><ul><li>Public Health problem (Quantitative BOD)
  37. 37. Impact</li></ul>Clinical spectrum (Severity)<br />Mortality<br /><ul><li>Communicability (Epidemic potential)
  38. 38. Preventability (in terms of feasibility & cost)
  39. 39. Risk perception </li></ul>Global health organizations<br />National authority<br />NGO<br />People<br /><ul><li>Political pressure</li></ul>Akhilesh Bhargava<br />16<br />
  40. 40. Prerequisites of an effective surveillance system<br /><ul><li>Standard case definition
  41. 41. Enumeration of Reporting units
  42. 42. System For Disease Surveillance</li></ul>Notifiable disease reporting System<br />Laboratory based surveillance<br />Hospital based surveillance<br />Population based surveillance<br />Akhilesh Bhargava<br />17<br />
  43. 43. Standard Case Definition<br /><ul><li>May not necessarily be the same as what clinician perceives
  44. 44. Depends on-</li></ul>Severity<br />Certainty of Diagnosis<br />Confirmed<br />Probable<br />Possible<br />Suspect<br />Non-case<br />Purpose<br />Sensitivity<br />Specificity<br />Akhilesh Bhargava<br />18<br />
  45. 45. Systems of Disease surveillance<br /><ul><li>Notifiable disease reporting System</li></ul>Morbidity<br />Mortality<br />Case investigation <br />Epidemic reporting<br />Field investigation<br />Drug and Biological use<br /><ul><li>Laboratory based surveillance
  46. 46. Hospital based surveillance
  47. 47. Population based surveillance</li></ul>Surveys<br />Services<br />Akhilesh Bhargava<br />19<br />
  48. 48. Sources of surveillance data<br />Mortality<br />Morbidity<br />Case reports<br />Epidemic reporting <br />Epidemic field investigations<br />Laboratory reporting<br />Surveys<br />Vector distribution studies<br />Biologics & drug distribution<br />Demographic & environmental data<br />News media<br />Akhilesh Bhargava<br />20<br />
  49. 49. Choice of Source depends on<br /> Disease<br /> Method used for identifying disease<br /> Program goals<br /> Resources-personnel/material<br /> Population involved<br /> Characteristics of disease occurrence<br />Akhilesh Bhargava<br />21<br />
  50. 50. Surveillance processes:<br />Routine surveillance<br />Reporting <br />Motivation<br />Procedural simplicity<br />Case definition<br />Active reporting<br />Sentinel physician reporting<br />Lab. Surveillance<br />Hospital surveillance<br />Absenteeism surveillance<br />Special surveillance<br />Data analysis (time, place, person)<br />Reports and evaluation<br />Akhilesh Bhargava<br />22<br />
  51. 51. Diseases under NPSCD#<br />Acute Flaccid Paralysis (AFP)<br />HIV/AIDS<br />Chickenpox<br />Cholera like Diarrhea<br />Diphtheria<br />Dysentery<br />Encephalitis<br />Fever Syndrome (fever of more than 6 days duration)<br />Fever with Bleeding<br />Hepatitis<br />Malaria<br />Measles<br />Meningitis<br />Rabies<br />Tetanus Neonatorum@<br />Tetanus@<br />Pulmonary Tuberculosis<br />Whooping cough<br />Any other disease of public health importance that might come up.<br /># But for two all are communicable disease<br />Akhilesh Bhargava<br />23<br />
  52. 52. Notifiable / Under Surveillance diseases<br /><ul><li>Notifiable
  53. 53. Cholera/
  54. 54. Plague/
  55. 55. Yellow fever
  56. 56. Notifiable as part of routine HIS</li></ul>Cholera<br /> Malaria<br /> Plague<br /> Polio<br /> Relapsing fever<br /> Influenza<br /> Rabies<br />Salmonellosis<br /><ul><li>Under WHO surveillance-</li></ul>Louse borne Typhus<br /> Relapsing fever<br /> Paralytic Polio<br /> Malaria<br /> Viral Influenza<br />Akhilesh Bhargava<br />24<br />
  57. 57. How to Notify<br />Notification-<br />1.Report of Cases- Individually<br /> Collectively<br />2.Report of Epidemics-<br /><ul><li>Case report universally required under International Health Regulations or as disease under WHO surveillance
  58. 58. Case reports regularly required whenever a disease occurs Report to local health authority by fastest means
  59. 59. Selectively reportable in endemic areas</li></ul>3.Obligatory reporting of Epidemics <br />Akhilesh Bhargava<br />25<br />
  60. 60. What steps do I take for Notification<br /><ul><li>Collect basic data-(Health facility)
  61. 61. Compile at
  62. 62. District,
  63. 63. State and
  64. 64. National level
  65. 65. Report: District – State - National Health authority to WHO</li></ul>Akhilesh Bhargava<br />26<br />
  66. 66. How do I Disseminate surveillance data:<br />Morbidity and mortality weekly report<br />Surveillance summaries<br />Surveillance reports<br />Annual summary <br />Medical literature<br />Akhilesh Bhargava<br />27<br />
  67. 67. General framework of Survrillance system<br />Engagement of stakeholders<br />Evaluation objective<br />System description<br />System performance<br />Conclusions and recommendations<br />Communication<br />Akhilesh Bhargava<br />28<br />
  68. 68. A. Engagement of stakeholders<br />Stakeholders ?<br /><ul><li>Ownersand the customers
  69. 69. Users of surveillance system information
  70. 70. Public health workers
  71. 71. Government
  72. 72. Data providers
  73. 73. Clinicians
  74. 74. Steering group?
  75. 75. A condition for change</li></ul>Akhilesh Bhargava<br />29<br />
  76. 76. B. Evaluation objective<br /><ul><li>Objective and methods
  77. 77. Specific purpose
  78. 78. Scope of evaluation
  79. 79. Methods
  80. 80. Document studies
  81. 81. Interviews
  82. 82. Direct observations
  83. 83. Special studies</li></ul>Akhilesh Bhargava<br />30<br />
  84. 84. C. System description<br />Public health rationale(why?)<br />Objectives (what?)<br />Operations (how?)<br />Resources (how much?)<br />Akhilesh Bhargava<br />31<br />
  85. 85. 1. Rationale for surveillance<br />The disease<br />Severity<br />Frequency<br />Communicability<br />International obligations<br />Costs<br />Preventability<br />Society<br />Public and mass media interest<br />Will to prevent<br />Availability of data<br />Akhilesh Bhargava<br />32<br />
  86. 86. 2. Objectives of system<br /><ul><li>Documented?
  87. 87. SMART?
  88. 88. Specific
  89. 89. Measurable
  90. 90. Action oriented (information for action)
  91. 91. Realistic
  92. 92. Time frame specified</li></ul>Akhilesh Bhargava<br />33<br />
  93. 93. 3. Operations of system<br /><ul><li>Health events under surveillance
  94. 94. Type of event:exposure -> infection -> disease / outbreaks -> outcome
  95. 95. Case definitions
  96. 96. Legal framework
  97. 97. Organisational framework
  98. 98. Components
  99. 99. Flow chart
  100. 100. Description</li></ul>Akhilesh Bhargava<br />34<br />
  101. 101. Components of system<br />Population under surveillance<br />Period of data collection<br />Type of information collected<br />Data source<br />Data transfer<br />Data management and storage<br />Data analysis: how often, by whom, how<br />Dissemination: how often, to whom, how<br />Confidentiality, <br />security<br />Akhilesh Bhargava<br />35<br />
  102. 102. 4. Resources for system operation<br /><ul><li>Funding sources
  103. 103. Personnel time
  104. 104. Other costs
  105. 105. Training
  106. 106. Mail
  107. 107. Forms
  108. 108. Computers</li></ul>Akhilesh Bhargava<br />36<br />
  109. 109. Importance of evaluation<br /><ul><li>Quality
  110. 110. Often neglected
  111. 111. Basis for improvements
  112. 112. Obligation
  113. 113. Does the system deliver?
  114. 114. Credibility of public health service
  115. 115. Learning process
  116. 116. ”Do not create one until you have evaluated one”</li></ul>Akhilesh Bhargava<br />37<br />
  117. 117. Goals of Surveillance Evaluation:<br />Prioritizes health events under surveillance<br />Surveillance systems meet objectives<br />Surveillance systems operate efficiently<br />Akhilesh Bhargava<br />38<br />
  118. 118. System performance<br />Does it work?<br />System attributes<br />Simplicity<br />Flexibility<br />Data quality<br />Acceptability<br />Sensitivity<br />Positive predictive value<br />Representativeness<br />Timeliness<br />Stability<br />Is it useful?<br />Use of information<br />Users<br />Actions taken<br />Link to objectives<br />Akhilesh Bhargava<br />39<br />
  119. 119. Data quality<br />Completeness<br />Proportion ofblank / unknown responses<br />Simple counting<br />Validity<br />True data?<br />Comparison<br />Records inspection<br />Patient interviews<br />Akhilesh Bhargava<br />40<br />
  120. 120. Evaluation of Surveillance system3 basic <br />Does the system address an important public health problem?<br />Does it accomplish the Objectives (purpose) of the system?<br />Does the system have the right combination of attributes to achieve its purpose?<br />Akhilesh Bhargava<br />41<br />
  121. 121. Does the system address an important public health problem?<br />Can it measure-<br /><ul><li>Disease burden</li></ul>Incidence/prevalence<br />Severity<br />Lost productivity<br />Premature mortality<br />Medical care costs<br /><ul><li>Potential burden</li></ul>Emerging problems<br />Problems under control<br /><ul><li>Preventability</li></ul>Akhilesh Bhargava<br />42<br />
  122. 122. Does it meets the Goal<br />Reduction in- <br />Morbidity<br />Mortality<br />Akhilesh Bhargava<br />43<br />
  123. 123. Does it accomplish the Objectives<br />Projects NHD and trends ?<br />Quantifies morbidity / mortality ?<br />Detects changes in epidemiologic pattern of disease ?<br />Evaluates hypotheses ?<br />Identifies and evaluates control/ prevention measures ?<br />Detects epidemics ?<br />Leads to public health action ?<br />Stimulates research ?<br />Akhilesh Bhargava<br />44<br />
  124. 124. Meeting objectives?<br /><ul><li>Has information produced?
  125. 125. Trends
  126. 126. Outbreaks
  127. 127. Future impact
  128. 128. Cases for further studies
  129. 129. Was information used, and by whom?
  130. 130. Actions: list
  131. 131. Consequences: list</li></ul>Akhilesh Bhargava<br />45<br />
  132. 132. Does it have right combination of Attributes<br />Sensitivity (ability to detect all cases)<br />Specificity (non-cases not reported)<br />Predictive value (Reported are real)<br />Representative<br />Timeliness<br />Akhilesh Bhargava<br />46<br />
  133. 133. Limitations<br />Severe events need treatment (Treatment sought alters the course of disease)<br />Laboratory facilities- availability<br />Reporting-Timeliness and accuracy<br />Sources for identifying mild or sub clinical cases <br />Support of Public Health system<br />Akhilesh Bhargava<br />47<br />
  134. 134. A good Surveillance System does not necessarily ensure making of right decisions; but it reduces the chances of wrong ones<br />Akhilesh Bhargava<br />48<br />