Public Health Surveillance

Public Health
Surveillance
Presenter: Dr. Uroosa Farooq
Department of Community Medicine ,SKIMS ,Srinagar
India.

Table of contents:
1.Introduction.
2.Surveillance.
3.Uses of surveillance.
4.Types of surveillance.
5.NSPCD.
6.IDSP.
7.Steps of an outbreak investigation.
8.Success stories about surveillance.

 The first recorded epidemic in history was
the great pestilence in Egypt during 3180
BC.
 This was the starting point of collecting and
organizing data.
 Some of the major epidemics in the history
of public health are summarized in table
below:
Historical origins of surveillance:

CDC defines epidemiological surveillance as “the
ongoing and systematic collection, analysis and
interpretation of health data essential to
planning, implementation and evaluation of
public health practice and programmes closely
integrated with timely dissemination of these
data to those who need to know”.
SURVEILLANCE IS- “INFORMATION FOR
ACTION”
SURVEILLANCE :

 The idea of collecting data, analysing them,
and considering a reasonable response stems
from Hippocrates, a Greek physician who
lived between 460 – 370 BC. In his book,
‘On Airs, Waters and Places’, when writing
on disease occurrence, Hippocrates made a
distinction between the endemic state as the
steady state of the disease, and the epidemic
as the abrupt change in incidence of disease.
 John Graunt (1620-1674) introduced
systemic data analysis.

 Samuel Pepys (1633-1703) started
epidemic field investigation.
 William Farr (1807-1883) founded the
modern concept of surveillance.
 John snow (1813-1858) linked data to
intervention .
 Alexander Langmuir (1910-1993) gave the
first comprehensive definition of surveillance.
(Bernard C. K. 2012)

 In 1741, the legislation for surveillance
was first introduced in America, when
Rhode Island passed an act requiring
tavern keepers to report contagious
disease among their patrons.
 Regular reporting of smallpox, yellow
fever, and cholera was made an act.
France was the first country to make
health of people as the responsibility of
state.
Legislations for surveillance :

1.To determine incidence of disease.
2.To know the geographical distribution or
spread of disease/event.
3.Identify population at risk of that
disease/event.
4.To capture the factors and conditions
responsible for occurrence and spread of a
disease.
USES OF EPIDEMIOLOGICAL SURVEILLANCE:

6. To predict the occurrence of epidemic
and control epidemic.
7. To evaluate the effectiveness of an
intervention or programme .
8. To assess the disease burden in the
community or health needs of
community.
5.Monitor trend of disease over a long –
time period.

1.Detection and notification of health event.
2.Investigation and confirmation
(epidemiological , clinical, laboratory).
3. Collection of data.
4. Analysis and interpretation of data.
5. Action to be taken
6. Feed back and dissemination of results.
Steps of Surveillance system:

1. Community level surveillance.
2. Routine reporting system.
3. Active and passive surveillance .
4. Sentinel surveillance.
5. Surveys and special studies.
6. Case and outbreak investigation.
7. Verbal autopsy.
8. Laboratory surveillance.
9. Entomological surveillance.
A .Surveillance methods for data collection:

ASHAs, Anganwadi workers, Self help groups ,
village panches
Report births, deaths, outbreaks and
unusual events
Informants at community level need to be
contacted on regular basis.
1.Community level surveillance:

 Health staff collects information about
number of cases of reportable diseases
and deaths that occur in relation to all
national health programmes .
 This system relies on government
established system of sub centres ,
PHCs, CHCs and hospital data.
 Whosoever comes to these facilities are
recorded and reported .Thus called
passive routine reporting system.
2.Routine reporting system:

3.Active surveillance Passive surveillance
1.Means actively looking or
searching for a particular type or
group of diseases, is useful in
detecting these unreported cases.
Collection of data from persons,
themselves reporting to a facility
(hosp., clinic, sub Centre, PHC
and CHC,)
2.It involves active participation
of health personals as well as the
community .
At times during outbreak
investigator may conduct what is
sometimes called stimulated or
enhanced passive surveillance by
sending a letter describing the
situation and asking for reports
of similar cases.
3.Degree of reporting is more
complete.
4.Important strategy for small
pox and guinea worm.
5.Its importance for malaria
control is still going on strong.
6.It has also been undertaken for
acute flaccid paralysis.

 A small number of health units are selected
to report cases of diseases and deaths that
are seen or diagnosed at their facility.
 These sentinel sites also collect and report
additional information such as age ,
immunization status and other details.
 Staff at sentinel sites is given special
training and supervised to ensure that
reporting is complete and accurate.
4.Sentinel surveillance:

 Hospital( infectious diseases, TB, Pediatric
hospital)
 Health centre
 Antenatal clinics
 STD clinic
 Laboratory
 Rehabilitation centre
which attend large number of particular type of
cases can be considered as a possible sentinel site.
Common sentinel sites:

 Large attendance of patients with particular
disease.
 Diagnosis is reasonable ,accurate and
laboratory support is available.
 Good recording and reporting facilities
available.
 Willingness to submit regular report.
Minimum criteria need to be observed in selection of
sentinel Centre :

 Sample surveys or disease surveys is an
active and efficient method of surveillance,
which can complement the other methods.
 Two surveys done at an interval of several
years apart may be able to demonstrate
changes in disease incidence.
 The first survey for collecting reliable baseline
epidemiological information and the
subsequent one for evaluation of the control
programme or intervention. e.g.,
5. Surveys and special studies:

Survey on blindness
at different points
in time in India
provides
information on
prevalence of
blindness and effect
of interventions on
blindness.
National oral health
survey and fluoride
mapping provides
useful information on
oral health status
and problems.
Survey of risk
factor for non-
communicable
diseases is being
undertaken at 3-
5 years interval
under IDSP .

 Surveys are difficult to conduct .
 Relatively expensive .
 Highly skilled persons with organizational
abilities are required.
 The sample size, questionnaires and forms
must be well designed to avoid bias and
misinterpretation of data.
 Some diseases require laboratory back-up for
accurate diagnosis, which make the surveys
even more difficult.
Limitations:

6. Case and outbreak Investigation:
An out break investigation
is an investigation of many
cases . However , when the
occurrence of a particular
disease is very low, Polio for
example , even one case can
be considered as an out
break.
Case investigation is an
investigation of a single
case of a disease or death.

7.Verbal Autopsy:
 It is a special technique for investigation of
cause of death.
 Trained worker or investigator conducts an
in-depth investigation of the death (
maternal or infant or any other death)
through interviews with the mother or any
one else who was a witness to the death and
the circumstances leading up to it.
 The investigations are done on a standard
designed format or protocol.

Purpose:
1.To ascertain the most probable cause of
death.
2.Whether the death could have been
prevented or avoided by timely and
appropriate measures.
3.Workers can educate community as to
how to prevent deaths as also common
causes of death in the community .

Laboratory testing confirms the syndromes of
presumptive cases and helps in diagnosis of
cases for case management.
8. Laboratory surveillance :
Regular surveillance for vectors of disease under
national vector –born disease control
programme is being done to know vector
density and sensitivity to insecticides.
9. Entomological surveillance:

B. Compilation and transmission of data:
 The cases that have been detected and
recorded need to be compiled and
transmitted to the next level on regular
basis once a week or daily .
 This could be done on a fixed date from
each type of unit . All reporting
units/centres will provide zero reporting if
no cases were detected.

 The designation of the person responsible for
data compilation and transmission at each
level has been identified (pharmacist,
computer statistical officer , lab technician
and medical officer).
 The health workers, medical officers of PHCs
and sentinel private practitioners will
provide regular reports on prescribed
formats on every Monday.

C. Analysis and interpretation:
 The analysis should be encouraged at each
level of surveillance system. Data are analyzed
by count, divide and compare principles and
then displayed by time, place and person
analysis .
 The workers should learn to interpret the
data they are collecting and thereby they
will have better understanding of the needs of
their community .

 The surveillance data can be easily
tabulated in three ways: summary tables,
disease charts and maps , which show the
number of cases of disease for each
reporting week and month. Data after
analysis becomes useful information for
action.

D. Action:
 Surveillance without action is useless .
 Action for malaria surveillance is full
therapeutic treatment, radical treatment and
selective spray programme and to control
breeding of vector as also to educate people .
 Similarly , action for outbreak of polio
necessitates mass polio vaccination or
outbreak response immunization .
 Outbreak of viral hepatitis needs super
chlorination of water supply or boiling of
water apart from personal hygiene.

E. Feedback:
 To ensure that reporting units at various
levels remain motivated and involved in the
surveillance process, there must be regular
communication back from higher levels of
programme management to lower levels .
 The feedback should include comments on
the performance and quality in recording
and reporting of cases and suggestions in
solving problems in collection of data.

NATIONAL SURVEILLANCE PROGRAMME
FOR COMMUNICABLE DISEASE (NSPCD):
 The Government of India launched NSPCD
during 1997-1998. Main objective was to
strengthen the surveillance system of
communicable diseases and developing
capabilities at state and district level so
that disease outbreak can be detected early
in order to institute rapid response to avert
large number of morbidity and mortality.
 The programme was in operation in 101
districts in the country. Now it has been
integrated with IDSP.

INTEGRATED DISEASE SURVEILLANCE
PROGRAMME (IDSP) :
 In the year 2004 Government of India
with World Bank assistance has
launched a project intends to cover all
states by phased manner.
 IDSP is proposed to continue as
disease surveillance and Response
Programme in 12th plan.

 IDSP is a decentralized , state based
surveillance programme in the country.
 It is intended to detect early warning
signals of impending outbreaks and help
initiate an effective response in a timely
manner.
 It is also expected to provide essential data
to monitor progress of on-going disease
control programmes and help allocate
health resources more efficiently.

Why called integrated:
 IDSP integrates both public and private sector
by involving the private practitioners, private
hospitals , private labs, NGOs , etc and also
emphasis on community participation
 Integrates communicable and non-
communicable diseases . Common to both of
them are their purpose in describing the
health problem, monitoring trends, estimating
the health burden and evaluating programmes
for prevention and control.

 Integration of both rural and urban health
systems as rapid urbanization has resulted in
the health services not keeping pace with the
growing needs of the urban populace. The
gaps in receiving health information from
the urban areas needs to be bridged
urgently.
 Integration with the medical colleges (both
private and public) would also qualitatively
improve the disease surveillance especially
through better coverage.

Phase I (2004-05)
Madhya Pradesh, Andhra, Himachal,
Karnataka, Kerala, Maharashtra, Mizoram,
Tamil Nadu & Uttaranchal
Phase II (2005-06)
Chattisgarh, Goa, Gujarat, Haryana, Orissa,
Rajasthan, West Bengal, Manipur, Meghalaya,
Tripura, Chandigarh, Pondicherry, Nagaland,
Delhi
Implemented in phase manner:
Phase III (2006-07)
UP, Bihar, J&K, Punjab, Jharkhand,
Arunachal, Assam, Sikkim, A&N Island,
D&N Haveli, Daman & Diu, Lakshadweep

Objectives:
1. Integrate all existing surveillance activities of
national disease control/eradication
programmes at the district level .
2. Establish system of data collection, collation,
compilation, analysis and feedback by using
information technology.
3. Improve laboratory support for disease
surveillance.
4. Develop human resources for disease
surveillance and action (RRT).
5. Involve all stake holders including private
sectors and communities in surveillance.

 Upgradation of laboratories.
 Upgradation of information technology
and communication.
 Human resources and development (
training- consultant / contract staff).
 Operational activities response. Monitoring
and evaluation.
Project activities:

Target Diseases for Surveillance under IDSP
Regular surveillance Sentinel surveillance Regular periodic
surveys
Malaria HIV/HBV,HCV For non-communicable
disease risk factors:
Acute diarrheal disease Water quality
monitoring
Anthropometry
Typhoid Outdoor air quality Physical activity
Tuberculosis B.P.
Measles Tobacco
Polio Diet
RTA, Plague ,
Meningoencephalitis,
Hemorrhagic fevers
Additional State Priorities :
Each state may identify up to five additional
conditions for surveillance.

•Syndromic
–Diagnosis made on the basis of clinical
pattern by paramedical personnel and
members of community (ASHA).
•Presumptive
–Diagnosis is made on typical history
and clinical examination by medical
officers.
•Lab. confirmed
–Clinical diagnosis confirmed by
appropriate laboratory identification.
Types of surveillance in IDSP:

Fever
<7 days with no localizing signs
with rash
with altered sensorium/convulsions,
bleeding skin/gums
>7 days
Cough >3 weeks
Acute Flaccid Paralysis
Diarrhea
Jaundice
Unusual events causing death/hospitalization
Syndromic surveillance

INFORMATION FLOW OF THE WEEKLY
SURVEILLANCE SYSTEM
Sub-centres
P.H.C.s
C.H.C.s
Dist. hosp.
Programme
officers
Pvt. practitioners
D.S.U.
P.H. lab.
Med. col.
Other Hospitals:
ESI, Municipal
Rly., Army etc.
S.S.U.
C.S.U.
Nursing homes
Private hospitals
Private labs.
Corporate
hospitals

DISTRICT SURVEILLANCE COMMITTEE
Chairperson*
District Surveillance Committee
District Surveillance Officer
(Member Secretary)
CMO
(Co. Chair)
Representative
Water Board
Superintendent
Of Police
IMA
Representative
NGO
Representative
District Panchayat
Chairperson
Chief District PH
Laboratory
Medical College
Representative
if any
Representative
Pollution Board
District Training Officer
(IDSP)
District Data Manager
(IDSP)
District Program Manager
Polio, Malaria, TB, HIV - AIDS
* District Collector or District Magistrate

Chairperson*
State surveillance committee
Director Health Service
Director Public
Health (Co. Chair) Director Medical Education
Representative
Water Board
NGO
Medical Colleges
State Coordinator
Representative
Department of Home
State Program Managers
Head, State Public
Health Lab
IMA
RepresentativeRepresentative
Department of Environment State Surveillance Officer
(Member Secretary)
State Training Officer
State Data Manager IDSP
STATE SURVEILLANCE COMMITTEE
* State health secretary

Chairperson*
National surveillance
committee
Director General
Health Services
(Co. Chair)
Director General
ICMR
PD
(IDSP)
JS
(Family Welfare)
Director
NICD
Director
NIB
National Program Managers
Consultants
(IndiaCLEN / WHO
/ Medical College
/others)
NGO
IMA
Representative
Representative
Ministry of Home
Representative
Ministry of Environment National Surveillance Officer
(Member Secretary)
* Secretary health and secretary family welfare
NATIONAL SURVEILLANCE COMMITTEE

Form ‘S’ (Suspect Cases) Health Workers
(Sub Centre)
Form ‘P’ (Probable Cases)
Doctors (PHC, CHC, Pvt. Hospitals)
Form ‘L’ (Lab Confirmed Cases)
Laboratories
Reporting Forms

Form Level of Laboratory Responsibility of
Reporting
Form
L1
Peripheral Laboratory at
PHC/CHC
Laboratory
Assistants/Technician
through MO I/c
Form
L2
District Public Health
Laboratory,
Labs of District Hospital,
Private
and other Hospitals & Private
Labs.
I/c
Microbiologist/Pathologi
sts
Form
L3
Labs in Medical Colleges, other
tertiary institutions,
Reference Labs.
Head, Microbiologist
Department
Laboratory Reporting

ICMR
National
Programs
CBHI
NCDC
CSU
Outbreak investigation
and rapid response
Non-communicable
diseases
surveillance
MIS and report
Programme monitoring
NVBDCP RNTCP RCH NACP
W.H.O. E.M.R.
LINKAGES OF THE CENTRAL SURVEILLANCE
UNIT AT THE CENTRAL LEVEL

Rumor register:
 The rumor register is to be maintained in
each public health facility.
 Source of information from the community
should be verified to identify outbreaks.
 It is an important source of information and
should not be neglected.
 On the other hand, key informants in the
community should be cultivated, so they
become the eyes and ears of the health
services in the community.

 The medical officer in charge of the public
health facility should investigate all rumors
of epidemic prone diseases recorded in the
rumor registry.
 The data is sent at weekly intervals to the
district surveillance officer along with the
weekly reports of syndromic surveillance.

Community Informants:
Public sector
Private sector
Rural/Urban Rural/Urban
Teachers , AWWs, Panchayat
members, Ward members,
ASHA
Health club, Youth club,
Farmer’s club leaders.
Media is an effective source of information on any unusual health event in the
community. This important source should not be neglected and ignored by the
health authorities.
Media:

 Central Surveillance Unit (CSU), New Delhi
 State Surveillance Unit (SSU), Barzulla,
Srinagar
 Kashmir Division has one State
Surveillance Unit
•Two Sentinel Surveillance units one each at
GMC Srinagar and Sheri Kashmir Institute of
Medical Sciences (SKIMS)
 District Surveillance Unit (DSU)

STATE SURVEILLANCE OFFICE-
State Surveillance Office-
Epidemiologist, Microbiologist, Data
Manager, Data Entry Operator and
Financial Consultant
District Surveillance Unit-
Epidemiologist, Data Manager, Data
Entry Operator
(12 Kashmir Districts)

SURVEILLANCE SYSTEM IN KASHMIR

Steps of an outbreak Investigation:
1.Verification of an outbreak.
2.Confirmation of an outbreak.
3.Confirmation of an etiology.
4.Find cases systematically and record information.
5.Epidemiological investigation.
6.Generation of Hypothesis.
7.Verification of hypothesis.
8. Response to an outbreak.
9. Report on outbreak.

SUCCESS STORIES OF
SURVEILLANCE

In addition to vaccination ,Surveillance played an
important role in eradication of small pox.
Surveillance had reduced morbidity and mortality by
measles to a greater extent and is one of the goals and
objectives in multiyear strategic plan developed by
Government of India in the year 2005.
In 1997 the National Polio Surveillance Project (NPSP)
was established as a joint collaboration between the
World Health Organization and the Ministry of Health
and Family Welfare, GoI, with the primary objective to
intensify surveillance for polio eradication through
detection and investigation of childhood Acute Flaccid
Paralysis (AFP).

Measles surveillance:
 Establishment and maintenance of a surveillance
system is important to ensure timely notification
of all measles cases.
 All measles outbreaks should be serologically
confirmed to differentiate them from other fever
and rash outbreaks.
 The surveillance data should be analyzed at all
levels to determine and improve the
immunization strategies.

1.Case definitions:
 Clinical measles.
 Laboratory confirmed measles.
 Epidemiologically confirmed measles.
2. Measles Surveillance structure :
 Surveillance activities at the local level.
 Surveillance activities at the district level.
 Surveillance activities at the state level.

1.Surveillance activities at the local level:
Reporting units: Medical
colleges, Dist. Hosp., Pvt.
Hosp., CHC, PHC and
Pediatric hosp. 10,000 RU
in India.
Informer units: Child specialists,
pvt practitioners and religious
places. 15,000 IU in India
RU has a designated N.O. for
AFP/Measles surveillance.RU
should report all measles cases
in weekly report. This report
would be sent to the dist. even
when there are no AFP
/Measles cases.
IU should notify the district
whenever they come across a
measles case. They need not
send a weekly report but should
inform the district (DIO/SMO)
on seeing a measles case.

Activities when measles cases are identified at the
reporting unit:
RU Medical officer/Physician/Nurse who see patient with measles should
inform the designated nodal officer.
NO should note down the details of the measles case in the VPD –
H002 form.
NO at each RU should report to the DIO/SMO by Monday of each
week.
Even if measles cases are not detected by the RU during the week , a
zero report should be sent using VPD-H002 form.

2.Surveillance activities at the district level:
On behalf of the DIO, the designated person at each district should
collect the VPD-H002 forms from all reporting units, collate them in
VPD-D001 form and compile the district report.
DIO should send this routinely every week to the State EPI
officer/State SMO by Tuesday of each week.
VPD-D002 form should be used to track completeness and timeliness
of reporting from the reporting units . This information should be
sent on a quarterly basis by the DIO to the State Programme Officer.

Activities during active surveillance visits to reporting units and
informers:
During a visit to a RU the
DIO/SMO should meet the
head of the RU and the
NO, visit all relevant
departments and check
their inpatient and
outpatient registers to scan
for missed or unreported
AFP/Measles cases since the
time of the last visit . The
Active Case Search VPD-
D003 form should be
completed by recording the
visit and the outcome of
the active case search.
By meeting the informers in
person. The DIO/SMO can
emphasize the need to
report both AFP and
measles cases , check their
records/registers to scan for
any missed or unreported
cases since last visit and can
also identify their training
needs . The visit should also
be documented in the VPD-
D003 form separately
maintained for informers.

Actions if unreported measles case(s) are found on Active case search:
If the child is still admitted in the hospital , the RU should be
advised to report the case /s in the VAD-H002 form of the
following week. The data should be reconciled at the district
level in the VPD-D001 form and a potential outbreak if any,
identified and investigated.
If the child is discharged from the hospital , the information to fill
the VPD-H002 might not be available . Nevertheless reporting unit
should be advised to find the available information from the records
and report in the VPD-H002 form of the following week.
However if an unreported case is detected, detailed investigation of
the unreported measles/AFP case should be carried out immediately.

3.Surveillance activities at the state level:
On Wednesday, the SEPIO/State Programme Officer should collect
the information received in the VPD-DOO1 forms from all the
districts in the state and collate the district reports in VPD-S001
form.
This information should then be transmitted to the Assistant
Commissioner Immunization , Ministry of Health and Family Welfare,
Government of India, New Delhi.

COLLECTION, TRANSPORT AND
REPORTING RESULTS OF STOOL
SPECIMENS OF AFP CASE:

When To Collect Stool Specimen From A Case Of AFP:
 Two stool specimens must be collected from every AFP case.
Stool specimens must be collected within 14 days of onset of
paralysis to maximise the chances of isolating poliovirus.
 In case samples cannot be collected within 14 days, the
specimens should still be collected up to 60 days of paralysis
onset.
 The first specimen should be collected at the time of the case
investigation. If the child is not able to pass stool, leave the stool
collection kit and stool shipment carrier with frozen ice packs
with the family so that they can collect sample from the child
later.
 The second sample should be collected at least 24 hours after the
first specimen collection, because virus shedding may be
intermittent.

How To Collect A Stool Specimen:
 Use a clean plastic screw-cap container (It is not essential to
have a sterilized container).
 A label with the name, identification number of the case (the
EPID number), the specimen number and the date of collection
should be pasted on the side of the container.
 If possible, collect fresh stool from the child’s diapers, or get the
child to defecate onto a clean paper.
 Collect a volume of stool about the size of one adult thumb size
(8 grams). This amount of stool will allow additional testing, if
necessary.
 Use the spoon attached to the cap to place the specimen in the
sample bottle

Transportation Of Specimens:
 The specimens should be sent to the laboratory in “cold chain”.
 If there is a delay in shipment, after collection, the specimens
must be placed immediately in a deep freezer or a freezer
compartment of a refrigerator.
 As soon as both samples are collected, make arrangements to
ship the specimens immediately. Plan for the specimens to arrive
at the laboratory within 72 hours of dispatch.
 If this is not possible, the specimens must be frozen (at minus
20°C) and then shipped frozen, preferably with dry ice or with
cold packs that have also been frozen at minus 20°C.”
 If a cold chain is not properly maintained at all times during
transport, poliovirus will not survive in the stool specimen.

Matching Of Stool Specimens At The Laboratory:
 The receiving laboratory must maintain correct
records for each sample, using the EPID number to
identify each specimen.
 The epidemiological data from the surveillance system
and the laboratory data for each case will be linked
by this number.

Reporting Laboratory Results:
 Laboratories set a “turn-around time” of 28 days
or less as a goal for processing specimens, i.e. the
primary isolation result is reported to the
surveillance program no more than 28 days from
the time the specimen is received at the laboratory.
 In India Poliovirus Laboratory Network, specimens
from which a poliovirus is isolated are sent for
intratypic differentiation and for genetic sequencing
if wild virus is isolated.
 Results of these tests are sent to NPSU, who in turn
send these results to the field.

Stool specimen collection, storage and transportation:

Public Health Surveillance

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