Public Health Surveillance

Presenter: Dr. Uroosa FarooqDepartment 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 surveillance1.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 IDSPRegular

surveillanceSentinel 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 activityTuberculosis B.P.Measles TobaccoPolio DietRTA, Plague , Meningoencephalitis, Hemorrhagic fevers

Additional State Priorities : Each state may identify up to five additionalconditions 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 rashwith altered sensorium/convulsions, bleeding skin/gums>7 days

Cough >3 weeksAcute Flaccid ParalysisDiarrheaJaundiceUnusual events causing death/hospitalization

Syndromic surveillance

Flow of information

INFORMATION FLOW OF THE WEEKLY SURVEILLANCE SYSTEM

Sub-centres

P.H.C.s

C.H.C.s

Dist. hosp.

Programmeofficers

Pvt. practitionersD.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)

RepresentativeWater Board

Superintendent Of Police

IMA Representative

NGORepresentative

District PanchayatChairperson

Chief District PHLaboratory

Medical CollegeRepresentative

if any

RepresentativePollution Board

District Training Officer(IDSP)

District Data Manager(IDSP)

District Program ManagerPolio, Malaria, TB, HIV - AIDS

* District Collector or District Magistrate

Chairperson* State surveillance committee

Director Health Service

Director Public Health (Co. Chair) Director Medical Education

RepresentativeWater Board

NGO

Medical CollegesState Coordinator

RepresentativeDepartment of Home

State Program ManagersPolio, Malaria, TB, HIV - AIDS

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 ManagersPolio, Malaria, TB, HIV - AIDS

Consultants(IndiaCLEN / WHO / Medical College /others)

NGO

IMA Representative

RepresentativeMinistry of Home

RepresentativeMinistry 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/Technicianthrough MO I/c

Form L2

District Public Health Laboratory,Labs of District Hospital, Privateand other Hospitals & Private Labs.

I/c Microbiologist/Pathologists

Form L3

Labs in Medical Colleges, othertertiary institutions,

Reference Labs.Head, Microbiologist Department

Laboratory Reporting

ICMR

NationalPrograms

CBHI

NCDC

CSU

Outbreak investigation and rapid response

Non-communicable diseases

surveillanceMIS 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) •One DSU in each of the twelve (12) districts

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

RAPID RESPONSE TEAM:

INCLUSION INITIATIVE

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.

RECENT OUTBREAKS:

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:

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