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Key elements in a surveillance system Patrick Rolland EPIET / EUPHEM Intro Course 2012 &

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Presentation on theme: "Key elements in a surveillance system Patrick Rolland EPIET / EUPHEM Intro Course 2012 &"— Presentation transcript:

1 Key elements in a surveillance system Patrick Rolland EPIET / EUPHEM Intro Course 2012 &

2 & 2 Le fil rouge in surveillance? Surveillance is Information for action!

3 & 3 Good reminder: surveillance? Langmuir AD., 1963 Systematic collection, consolidation, analysis and dissemination of data on specific disease Thacker SB., 1996 The final link is the application of these data to prevention and control

4 & 4 Good reminder: surveillance loop Data collection Data analysis Information Action! Evaluation Objectives

5 & 5 Aim and content of the lecture Aim : To understand key elements in a surveillance system -From a clear understanding of the purpose -To the right dissemination of information Content -Main objectives of a surveillance system -Checklist of key elements, step by step

6 & 6 Main objectives of a surveillance system

7 & 7 Main objectives Describe : produce information in terms of TPP Alert : detect epidemics or emerging events Evaluate : assess prevention or control measures And also: Generate hypotheses for research Detect changes in health practice Plan public health actions and resources

8 & 8 But keep in mind the goal! Surveillance is Information for action! By implementation of prevention and control measures In order to reduce morbidity and mortality

9 & 9 Describe: Time = Graph Source: GP network Réseau unifié Week Incidence (per 100,000) Weekly incidence rate of flu-like syndromes, 2009-2012, France

10 & 10 Describe: Place = Map Weekly incidence rate of acute diarrhea (per 100,000) 1 to 7 march 2012, France Source: GP network Réseau sentinelles

11 & 11 Describe: Person = Table Severe cases of influenza, winter 2011- 2012, France Source: Intensive care units Network Characteristics of persons Burden

12 & 12 Alert: detect an epidemic Exceedence Week Weekly incidence of flu-like syndromes, 2007-2012, France Source: GP network Réseau sentinelles Incidence (per 100,000) Incidence Threshold

13 & 13 Emergence of W135 Alert: detect an emerging phenomena Invasive meningococcal infections by serogroup B, C, W135 et Y, 1985-2006, France Source: InVS, NRC for meningococci Year Number of cases B C W135 Y

14 & 14 Evaluate: prevention/control measure Cases of Pertussis, England and Wales, 1940-1999 Number of cases (x 1000) Year 0 80 40 Vaccinate coverage (%) Vaccination implementation

15 & 15 Evaluate: prevention/control measure Source: Notifiable disease, InVS Cases of legionellosis, 1988-2011, France Reinforced surveillance New investigation guide Urine antigen testing Number of cases Year Incidence (per 100,000) No cases Incidence

16 & 16 Key elements in a surveillance system

17 & 17 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

18 & 18 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

19 & 19 Justification of implementation Ask yourself two main questions: -Should this event be under surveillance? High frequency? High severity? High socioeconomic cost? -Do some prevention or control measures exist? And these two additional questions: -Do we have existing data that already answer? -Do we have resources to set up a new system?

20 & 20 Health events under surveillance Infectious diseases -Notifiable diseases -Health-care associated infections (HCAI) -Vaccine-preventable diseases -Food and waterborne diseases -Sexually transmitted infections (STI) -Zoonoses -Vector-borne diseases But also?

21 & 21 Health events under surveillance Chronic diseases and injuries: cancers, accidents, traumas, cardiovascular diseases, etc. Occupational health: cancers, musculoskeletal disorders, respiratory diseases, mental health, etc. Environmental hazards: air pollution, ionizing radiations, heat/cool waves, water/soil pollution, etc.

22 & 22 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

23 & 23 Objectives of the system Primary objective: To describe a health-related event in population-based or in a specific population With two possible aims (sometimes both): ­To alert by early detection of epidemics or emerging pathologies that need timely action ­To evaluate the efficiency of prevention or control measures

24 & 24 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

25 & 25 Passive and active system Consideration useful for discussion Passive: The data come to you ­Data collection based on existing information ­Simple, not burdensome but could be incomplete E.g.: notifiable diseases, deaths, emergency data Active: You go towards the data ­Data collection specially set up ­Good quality of data but required resources E.g. : injuries, non-notifiable infectious diseases, etc.

26 & 26 E.g. of passive system % of gastroenteritis among emergency consultations, seasons 2010-2011 and 2011-2012, Aquitaine, France Proportion of cases Week

27 & 27 E.g. of active system Cases of envenomation by Physalia Physalis reported by lifeguards, Aquitaine Atlantic Coast, Summer 2011, France Number of cases Day

28 & 28 Exhaustive vs. sentinel system Important consideration for data analysis Severe diseases or low-frequency diseases requiring timely action Exhaustive system (= all providers) E.g.: cancers registries, notifiable diseases High-frequency diseases or less-severe diseases Sentinel system (= selected providers) E.g.: seasonal flu, occupational diseases (except cancers)

29 & 29 E.g. of exhaustive system Cancers among women, Year 2005, Gironde, France Source: Cancer registry of Gironde Number of cases 1. Breast cancer 2. Colorectal cancer 3. Skin cancer Cancer causes

30 & 30 E.g. of sentinel system Prevalence of occupational diseases (except cancers), Year 2010, Region of Aquitaine, France Source: Sentinel Network of occupational physicians (n=92)

31 & 31 Case vs. syndromic system Case system (traditional system) ­Targets a defined health-related event E.g.: mesothelioma, Lyme disease, diabetes, etc.. Syndromic system (before diagnosis) ­For early detection, evaluation of event impact ­Based on existing activity data, real-time collection, analysis and interpretation data E.g.: emergency services, virology labs, deaths certificates, medicine sales, absence in schools, etc.

32 & 32 E.g. of case system Occupations at risk for mesothelioma, France Source: Program of Mesothelioma Surveillance (1998-2012), InVS Occupations Odds-ratio (95% CI)

33 & 33 E.g. of syndromic system % of gastroenteritis among emergency consultations, seasons 2010-2011 and 2011-2012, Aquitaine, France Proportion of cases Week

34 & 34 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

35 & 35 Case definition The heart of the system! Must be clear and simple Based on criteria: clinical, biological, epidemiological May include: -Classification (possible, probable, confirmed) -TPP (Time-Place-Person) information

36 & 36 Source: Case definitions of notifiable diseases Commission Decision 2008/426/EC – 28-IV-2008 E.g. for measles definition as notifiable disease Clinical criteria Laboratory criteria Epidemiological criteria Case classification

37 & 37 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart of data and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

38 & 38 Population under surveillance Depends on characteristics of health-event E.g.: Hemolytic Uremic Syndrome (HUS) -Rare disease that predominantly affects children, needs timely action in outbreak Population under surveillance (France): children (< 15 years) hosted in pediatric and nephrology hospital services (N=31)

39 & 39 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

40 & 40 Data providers and data sources Data providers: health professionals, laboratories, health insurance funds, civil status offices, etc. Data sources ­Administrative: death certificates, hospital systems, etc. ­Medical: patients folders, notifiable diseases, etc. ­Biological: virology, bacteriology, toxicology samples ­Environmental: air pollution sensors, individual ionizing radiations card for exposed workers, etc.

41 & 41 E.g. data provider: NRC (France) Anaérobies et Botulisme (LA) Arbovirus (LA) ATNC Brucella Borrelia (LA) Campylobacter & Helicobacter Charbon (LA) Chlamydiae Cytomégalovirus Enterovirus Escherichia coli & Shigella (LA) Francisella tularensis Gonocoques Haemophilus influenzae Legionella Leishmania Mycobactéries et résistance des mycobactéries Paludisme (2 co-responsables) Pneumocoques Résistance aux antibiotiques (LA) Rickettsia, Coxellia & BartonellaVirus de la rougeole StaphylocoquesVIH Streptocoques Virus Influenza Syphilis Virus entériques Trichinella Virus des hépatites A et E Toxoplasmose Virus des hépatites B, C et Delta Arbovirus Arbovirus & influenza virus en AG Charbon Borrelia Anaérobies et Botulisme Chimiorésistance du paludisme en Antilles Guyane Coqueluche et autres bordetelloses Corynebactéries toxinogènes Escherichia coli & Shigella Fièvres hémorragiques virales Leptospires Listeria Méningocoques Mycologie et antifongiques Peste et autres yersinioses Rage Salmonella Résistance aux antibiotiques Streptocoques (LA) Virus des Hépatites B & C (LA) Vibrions et cholera Virus Influenza 32 NRC and 31 AL Within hospitals, universities, other research institutes 15 NRC and 3 AL Pasteur Institute (Paris) 47 National Reference Centers and 34 Associated Laboratories One NRC per infectious disease

42 & 42 E.g. data source: ND (France) Botulisme Brucellose Chikungunya Dengue Fièvres typhoïdes et paratyphoïdes Hépatite aiguë A Infections invasives à méningocoques Légionellose Listériose Rougeole Saturnisme de lenfant mineur MCJ et ESST Toxi-infection alimentaire collective Tuberculose Choléra (RSI) Diphtérie Fièvres hémorragiques africaines Fièvre jaune (RSI) Paludisme autochtone et paludisme importés dans DOM Peste (RSI) Poliomyélite Rage Typhus exanthématique Charbon, Tularémie, Variole Infection à VIH quel quen soit le stade Hépatite aiguë B Tétanos Bioterrorism-related ND (n=3) Frequent ND (n=14)Infrequent ND (n=10) 27 notifiable diseases (ND) require surveillance and timely action Mésothéliome (entrée en 2012) 4 ND require surveillance only

43 & 43 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart of data and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

44 & 44 E.g. French form for mesothelioma notiable disease Anonymous data on patient diagnosis (by clinician&pathologist) Nominative data on patient and provider Dates and signatures of provider and sanitary authority

45 & 45 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

46 & 46 E.g. of flow chart: ND (France) Patient Health professionals, laboratories, etc. Reference Centers Experts Networks Clinicians/Pathologists Partners National/International Public Health High Council Politic of Health Alert Declaration Ministry of Health Health Regional Agencies Alert

47 & 47 Data transmission Reliable and fast ­Electronic: e-mails, websites ­And: phone, fax and mail Low frequency ­Daily ­Weekly ­Monthly Secure ­Regularity, punctuality, exhaustiveness And dont forget the Zero reporting

48 & 48 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

49 & 49 Data validation and data analysis Data validation ­Missing data ­Duplicates Data quality Data analysis ­Indicators: frequency, severity ­Methods: descriptive, analytical ­Illustrations: tables, graphs and maps Keep in mind: Time-Place-Person!

50 & 50 Daily deaths, summers 1999-2002 vs. 2003, France E.g. of data analysis: time series Number of deaths Day (25 June to 19 august) Source: Syndromic Program, InVS Temperature (°C) Temperature Deaths 1999-2002 2003 1999-2002 2003

51 & 51 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

52 & 52 Dissemination/communication data Systematic and regular ­For stakeholders, decisions makers ­For other professionals, public, medias Adapted ­To Those who need to know ­To the urgency of the situation Format ­Report, article, flash news, press release etc. ­But also: phone, e-mail, fax, mail Factor of motivation/improvement

53 & 53 E.g. report at local level Point épidémio France, Bordeaux (InVS, south west) Weekly report on health status of population Topics: Outbreaks Seasonal pathologies Notifiable diseases Virology surveillance Deaths

54 & 54 E.g. report at international level WHO (Switzerland) CDC (USA)

55 & 55 E.g. press release At international level (e.g. Europe) At local level (e.g. France, Bordeaux)

56 & 56 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

57 & 57 Human and financial resources From the budget to the expenses ­Salaries, travels, equipments, furniture, etc. Useful to negotiate resources, check the workplan, assess the cost of the system

58 & 58 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

59 & 59 Data security and confidentiality Critical point in surveillance system Public heath data ­Often personal and private in nature ­Might directly identified individuals Take into account policies and protection for personal data ­Data collection often under laws

60 & 60 Key elements Justification of implementation Objectives of the system Types of system Case definition Population under surveillance Data providers and data sources Data elements and data collecting tools Flow chart and data transmission Data validation and data analysis Dissemination and communication data Human and financial resources Data security and confidentiality Evaluation of system

61 & 61 Aims of evaluation Ask yourself the fundamental question: Have the objectives been met? And these additional questions: -Did the system generate needed answers? -Was the information timely? -Was it useful for decisions makers? -How was the information used? -What could be done to improve the attributes? -Is it useful to continue the surveillance?

62 & 62 Simplicity : refers to structure and ease operation Flexibility : ability to adapt to changing needs Data quality : refers to data completeness&validity Acceptability : willingness of persons and organizations to participate Sensitivity : refers to proportion of detected cases by the system (A / A + C) The 9 attributes of a system (1)

63 & 63 PVP : refers to proportion of reported the cases that actually have the event (A / A + B) Representativeness : ability to describe the event over time and its distribution in the population Timeliness : reflects the speed between system steps of the system Stability : refers to reliability and availability The 9 attributes of a system (2)

64 & 64 Conclusion

65 & 65 Main messages Justification -Relevance of the event to be under surveillance -Existence of prevention and control measures Objectives and aims To describe – To alert – To evaluate To produce information for action In order to reduce morbidity and mortality Requirements -Good data, involvement of stakeholders -Regular evaluation of the system

66 & 66 One useful book 3rd edition September 2010 Lisa M. Lee et al.

67 & 67 Dont forget the surveillance loop! Data collection Data analysis Information Action! Evaluation Objectives

68 & 68 Le fil rouge in surveillance? Surveillance is Information for action!


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