MDS (PUBLIC HEALTH DENTISTRY)

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SURVEILLANCE OF
HEALTH EVENT
SEMINAR NO:4

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Contents
• Introduction
• Goals of Public Health Surveillance
• History of Public Health Surveillance
• Uses of Public Health Surveillance
• Types of Public Health Surveillance
• Surveillance system attributes
• Public Health Surveillance process
• Public Health Surveillance in India
• Integrated Disease Surveillance Program (IDSP)
• National Surveillance Programme for Communicable Diseases (NSPCD)
• Conclusion

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Surveillance:
An ongoing, systematic collection, analysis and interpretation of health-related data essential to the
planning, implementation, and evaluation of public health practice. (WHO)
Definition
SURVEILLANCE IS- “INFORMATION FOR ACTION”
Public health surveillance:
The ongoing, systematic collection, analysis, and interpretation of health-related data essential to
planning, implementation, and evaluation of public health practice, closely integrated with the
timely dissemination of these data to those responsible for prevention and control. (Thacker and
Beckelman , 1988)

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SURVEILLANCE
Infectious diseases
Chronic diseases Injury
Health service
uptake
Vector distribution
Environmental
diseases

5. Goal of Public Health Surveillance
Provide information that can be used for health action by public health
personnel, government leaders, and the public to guide public health
policy and programs.
5

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1662
• Graunt publishes natural and political observations made upon the bills of mortality, which
defines disease- specific death counts and rates.
1888
• Mandatory reporting of eleven communicable diseases and death certificates, in Italy
1893
• Publication of international list of causes of death by the International Statistical Institute
(founded in London in 1885)
1911
• Use of surveillance data from National Health Insurance, in the United Kingdom
1935
• First National Health Survey, in the USA
History of Public Health Surveillance

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1943
• First registry, the Danish Cancer Registry First Sickness Survey, in the United Kingdom
1963
• Langmuir formulates modern concept of surveillance in public health, emphasizing role in
describing health of populations.
1965
• Establishment of an Epidemiological Surveillance Unit in the Division of Communicable Diseases at
WHO headquarters, Geneva
1966
• First publication of Communicable Disease Surveillance Reports by WHO
1967
• Development of General Practitioners' Sentinel Systems, in the United Kingdom and the
Netherlands

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1980s
• Introduction of microcomputers allows more effective decentralization of data analysis and
electronic linkage of participants in surveillance networks.
1990s &
2000s
• internet is used increasingly to transmit and report data
2001
• Cases of anthrax associated with exposure to intentionally contaminated mail in US lead to
growth in “syndromic surveillance” aimed in early detection of epidemics

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Develop Develop hypotheses and stimulate research
Assess Assess effectiveness of programs and control measures
Monitor Monitor changes in infectious and environmental agents
Measure Measure trends and characterize disease
Estimate Estimate magnitude and scope of health problems
Detect Detect epidemics, health problems, changes in health behaviors
Identify Identify patients and their contacts for treatment and intervention
Uses of Public Health Surveillance

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An effective surveillance system has the following functions:
Functions
•detection and notification of health events
collection and consolidation of pertinent data
investigation and confirmation (epidemiological, clinical and/or laboratory)
of cases or outbreaks
routine analysis and creation of reports
feedback of information to those providing the data
feed-forward (i.e. the forwarding of data to more central levels)
reporting data to the next administrative level

11. Syndromic Surveillance
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Types of Public Health Surveillance
Limited by incompleteness of reporting and
variability of quality
Used in conjunction with specific epidemiologic
investigation
Sentinel Surveillance
• Reporting of health events by health
professionals who are selected to
represent a geographic area or a
specific reporting group
• Can be active or passive
Focuses on one or more symptoms
rather than a physician-diagnosed or
laboratory-confirmed disease
Passive Surveillance Active Surveillance
Diseases are reported by health care providers
Health agencies contact health providers seeking
reports
Simple and inexpensive Ensures more complete reporting of conditions

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•Individual surveillance: this is surveillance of infected persons until they are no
longer a significant risk to other individuals.
Local population surveillance: Eg: surveillance of malaria
National population surveillance: Eg: Surveillance of smallpox after the disease
has been eradicated.
International surveillance: At the international level the WHO maintains surveillance
of important diseases (Eg: influenza, malaria, polio, etc.) and gives timely warning to
all national governments.
Surveillance may comprise:

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Surveillance System Attributes
Sensitivity: To what extent does the system identify all targeted events?
Timeliness: How quickly are reports received?
Predictive value: How many of the reported cases meet the case definition?
Representativeness: How good is the system at representing the population
under surveillance?
Data quality: How complete and accurate are data fields in the reports received
by the system?
Flexibility: How easy is the system’s operation?
Acceptability: does their effort yield information that is useful to them?

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Source: https://www.youtube.com/watch?v=3IpE8dE4cVc
Health event
Action
Detection and notification
Health service
Laboratory
Data collection
and storage
Analysis and
Interpretation
Dissemination
of findings

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Public Health Surveillance Process
Data Collection
•Reported diseases or syndromes
•Electronic health records (e.g., hospital discharge data)
•Vital records (e.g., birth and death certificates)
•Registries (e.g., cancer, immunization)
•Surveys (e.g., National Health and Nutrition Examination Survey
[NHANES])
•Nationally Notifiable Disease Surveillance System (NNDSS)
•Internationally Notifiable Diseases:
Reporting to WHO is required for cases of
• Smallpox
• Poliomyelitis (wild type)
• Human influenza caused by any new subtype
• Severe acute respiratory syndrome (SARS)
Data Analysis
Data
Interpretation
Data
Dissemination
Link to Action
Data Collection

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Data Collection
Data Analysis
Data
Interpretation
Data
Dissemination
Link to Action
• Who will analyze the data?
• What methodology will they use?
• How often will they analyze the
data?
Surveillance Data Analysis by Place
Map Courtesy of the New York City Department of Health and Mental Hygiene
North Queens
Serosurvey Area
Data Analysis by Person
Characteristic
No. of
Patients (%)
Population
at Risk
Rate of
Infection per
Million
Population
Age (years)
0–19 2 (3) 2,324,081 0.9
20–29 1 (2) 1,553,981 0.6
30–39 3 (5) 1,549,111 1.9
40–49 1 (2) 1,177,190 0.8
50–59 9 (15) 867,331 10.4
60–69 12 (22) 814,838 16.0
70–79 18 (31) 534,785 33.7
≥80 12 (20) 281,054 42.7
Age category (years)
≥50 52 (88) 2,498,008 20.8
<50 7 (12) 6,604,363 1.1
Sex
Male 31 (53) 4,289,988 7.2
Female 28 (47) 4,812,383 5.8
Race
White 41 (69) 5,983,901 6.9
Nonwhite 9 (15) 3,118,470 2.9
Unknown 9 (15) -- --
Borough or county of
residence
New York City
Brooklyn (Kings) 3 (5) 2,300,664 1.3
Bronx 9 (15) 1,203,789 7.5
Manhattan 1 (2) 1,487,536 0.7
Queens 32 (54) 1,951,599 16.4
Staten Island
(Richmond) 0 379,999 0.0
New York State
Nassau 6 (10) 1,287,348 4.7
Westchester 8 (14) 847,866 9.1
Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York City area
in 1999. N Engl J Med. 2001;344:1807–14.

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Data Collection
Data Analysis
Data
Interpretation
Data
Dissemination
Link to Action
Data interpretation is closely coupled with data analysis
• Health agency newsletters, bulletins, or alerts
• Surveillance summaries and reports
• Medical and epidemiologic journal articles
• Press releases and social media
Data Dissemination Target Audiences
• Public health practitioners
• Clinicians and other health care providers
• Policy and other decision makers
• Community organizations
• The general public
Data
Dissemination

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Data Collection
Data Analysis
Data
Interpretation
Data
Dissemination
Link to Action
Link to Action
Monitor trends and patterns in disease, risk factors, and agents
Source: Centers for Disease Control and Prevention (CDC). National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and
1922-1949, passive reports to the US Public Health Service. Atlanta, GA: US Department of Health and Human Services, CDC. Available at:
http://www.cdc.gov/pertussis/images/incidence-graph.jpg.
Pertussis (Whooping Cough) Cases, by Year — United States, 1922–2000

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Public Health Surveillance-Based Action
Describe the
burden of or
potential for
disease
01
Monitor trends
and patterns in
disease, risk
factors, and
agents
02
Detect sudden
changes in
disease
occurrence and
distribution
03
Provide data for
programs,
policies, and
priorities
04
Evaluate
prevention and
control efforts
05

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• India needs effective disease
surveillance and equity in
health delivery programs for
taking corrective actions to
improve health conditions of
vulnerable populations.
• The outbreaks of plague
(1994, 2002), malaria(1995),
dengue (2006) in different
parts of the country further
highlighted the weaknesses in
the surveillance system.
Public Health Surveillance in India
Pilot, E., Roa, R., Jena, B., Kauhl, B., Krafft, T. and Murthy, G.V.S., 2017. Towards Sustainable Public Health Surveillance in
India: using routinely collected electronic emergency medical service data for early warning of infectious
diseases. Sustainability, 9(4), p.604.

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“India’s Public Health Surveillance by 2035” is a continuation of the
work on Health Systems Strengthening.
• This paper is a joint effort of Health Vertical, NITI Aayog, and Institute
for Global Public Health, University of Manitoba, Canada with
contributions from technical experts from the Government of India,
States, and International agencies.
• Public Health Surveillance (PHS) cuts across primary, secondary, and
tertiary levels of care.

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Vision Statement
In 2035, India’s Public Health Surveillance will:
1. Be a predictive, responsive, integrated and tiered system of disease and health surveillance that is inclusive of
prioritized, emerging and re-emerging communicable and non-communicable diseases and conditions. Readiness for
actions at community, facility and health and governance systems are key aspects of the response.
2. Be a system that is primarily based on de-identified individual level patient information which includes health care
facility and laboratory data as key sources, amongst others.
3. Serve public-good through the provision of meaningful ‘information for action’ to relevant stakeholders^, with due
attention to privacy and confidentiality of the individual, and enabled with a client feedback mechanism.
4. Provide regional/global leadership in compliance with International Health Regulations and management of events that
constitute a Public Health Emergency of International Concern

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Examples of action at different levels

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National Surveillance Programme for Communicable Diseases (NSPCD)
• NSPCD was launched by the Centre in 1997-98 in five pilot districts of the country (centrally
sponsored scheme) and over the years extended to cover 101 Districts in all 35 states and
UTs in the country.
• In this programme the states were the implementing agencies and NICD Delhi was the Nodal
agency for coordinating the activities.
• This programme was based on outbreak reporting (as and when outbreaks occur) with
weekly reporting of epidemic prone diseases directly from Districts (including nil reporting)
to the Centre.

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Main components:
To establish Early Warning System (EWS) so as to institute appropriate and timely
response for prevention & control of outbreaks
• Every state/UT and all the 101 districts had a trained multi-disciplinary Rapid Response
Team
• Rapid communications (through e-mails & fax)
• Strengthening of state and district laboratories for rapid confirmation of diagnosis
• Capacity development of health staff in the districts
• IEC (information, education and communication)

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Districts covered under NSPCD
1997-98 (25 districts)
1998-99 (20 districts)
2000-01(35 districts)
2001- 02 (20+1 districts*)
* The district of Shimla taken as
a special case during 2002-03

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Diseases/pathogens covered:
• Epidemic prone communicable diseases- acute diarrhoeal diseases
including cholera, viral hepatitis, dengue, Japanese encephalitis,
meningitis, measles, viral haemorrhagic fevers, leptospirosis, others.
• Pathogens with bioterrorism potential
• Drug resistant pathogens

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Expected outcome:
 Early detection of outbreaks
 Early institution of containment measures
 Reduction in morbidity & mortality
 Minimize economic loss

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The intent of the program is:
• to detect early warning signals
of impending outbreaks
• to help initiate an effective
response in a timely manner
• to provide essential data to
monitor progress of on-going
disease control programs
• to help allocate health
resources more efficiently
Launched by Union Minister of Health and Family Welfare on 8th November 2004 as a decentralized, state-based
surveillance program.
INTEGRATED DISEASE SURVEILLANCE PROGRAM (IDSP)

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The IDSP has categorized the public health response in order to address concerns raised
through surveillance by three levels:
Many states have also instituted ‘Media Scanning and Verification Cells’ as a function of the
SSU, and very often, these serve as the ‘Early Warning System’ for a political and
programmatic response to a disease outbreak.

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Surveillance activities in India are largely either Event Based Surveillance or Indicator Based Surveillance.
Event based Surveillance is usually restricted to events of public health importance, whereas indicator-based
surveillance includes monitoring of trends, occurrence of new events or compilation and analyses of a number of
events.
Activities that contribute to Disease Surveillance is:
• Notification
• Sentinel surveillance
• Active and passive surveillance
• Vector surveillance
• Laboratory surveillance
• Sample surveys
• Registries
• Outbreak investigation
• Special studies

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The Organization of Disease Surveillance in India:
CENTRAL SURVEILLANCE UNIT (CSU)
• CSU is integrated administratively and financially with the National Centre for Disease Control (NCDC), New Delhi
and established by the Ministry of Health and Family Welfare for the Global Health Security Agenda (GHSA).
• The CSU has 14 technical centers/divisions, including epidemiology, microbiology, zoonosis, medical entomology
and vector management, IDSP, Centre for AIDS and related Diseases, biochemical and toxicology, biotechnology,
parasitic diseases, malariology and coordination, occupational and environmental health, non communicable
diseases, statistics and M&E, planning, budget and administration.
• The CSU runs a two-year MPH course in Field Epidemiology.
STATE SURVEILLANCE UNIT (SSU)
• There is SSU in each State/UT with a regular officer identified as State Surveillance Officer (SSO).
• The SSO is supported by 7 contractual staff who include Training, Finance, Data Managers, Epidemiologist,
Microbiologist, Entomologist and recently included Veterinary consultant.
DISTRICT SURVEILLANCE UNIT (DSU)
• One in each district with a regular officer as District Surveillance Officer (DSO), supported by 3 contractual staff.

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Phase II (05-06) : – Chattisgarh, Goa, Gujarat,
Haryana, Orissa, Rajasthan, West Bengal,
Manipur, Meghalaya, Tripura, Chandigarh,
Pondicherry, Nagaland, Delhi
Phase-I (04-05): Madhya Pradesh, Andhra,
Himachal, Karnataka, Kerala, Maharashtra,
Mizoram, Tamil Nadu & Uttaranchal
Phase III (06-07): UP, Bihar, J&K, Punjab,
Jharkhand, Arunachal, Assam, Sikkim, A&N
Island, D&N Haveli, Daman & Diu, Lakshadweep
Phasing of Integrated Disease Surveillance Project

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Target diseases in IDSP:

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COVID-19 AND SURVEILLANCE-VISION 2035

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INFORMATION LOOP OF PUBLIC HEALTH SURVEILLANCE

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The Way Forward: Public Health Surveillance in India

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References
1. Park, Park’s Textbook of Preventive &Social Medicine, 25th Edition, Jabalpur: Banarsidas Bhanot,2019.
2. Rothman, K., Greenland, S., & Lash, TL. (2008). Modern Epidemiology, 3rd Edition. Lippincott Williams &
Wilkins.
3. Pilot, E., Roa, R., Jena, B., Kauhl, B., Krafft, T. and Murthy, G.V.S., 2017. Towards Sustainable Public Health
Surveillance in India: using routinely collected electronic emergency medical service data for early warning of
infectious diseases. Sustainability, 9(4), p.604.
4. Declich, S. and Carter, A.O., 1994. Public health surveillance: historical origins, methods and
evaluation. Bulletin of the World Health Organization, 72(2), p.285.
5. https://www.cdc.gov/training/publichealth101/surveillance.html#anchor_resources – Public Health
Surveillance
6. https://www.who.int/immunization/monitoring_surveillance/burden/vpd/en/ - Public Health Surveillance
7. https://niti.gov.in/index.php/node/1395 - Vision 2035 Public Health Surveillance In India