1. Public Health Surveillance By :Dr Snehal Moderator : Dr D.G.Dambhare Public Health Surveillance By :Dr Snehal Moderator : Dr D.G.Dambhare 1

2. Framework History Surveillance Types of surveillance Public Health Surveillance Uses of surveillance Health surveillance in India National surveillance programme for communicable disease (NSPCD) IDSP (Integrated Disease Surveillance Programme ) History Surveillance Types of surveillance Public Health Surveillance Uses of surveillance Health surveillance in India National surveillance programme for communicable disease (NSPCD) IDSP (Integrated Disease Surveillance Programme ) 2

3. History 3 Hippocrate :The idea of collecting data, analysing them, and considering a reasonable response 1300s:The first public health action 1776:Johann Peter Frank in Germany advocated a more extensive monitoring of health. 1839-1879: William Farr founder of modern concept of Surveillance 1900: Farr’s efforts at health monitoring were extended by Edwin Chadwick, who investigated the relationship between environmental conditions and disease. 1893:Lemuel Shattuck recommended standardized nomenclature for cause of disease and death. Hippocrate :The idea of collecting data, analysing them, and considering a reasonable response 1300s:The first public health action 1776:Johann Peter Frank in Germany advocated a more extensive monitoring of health. 1839-1879: William Farr founder of modern concept of Surveillance 1900: Farr’s efforts at health monitoring were extended by Edwin Chadwick, who investigated the relationship between environmental conditions and disease. 1893:Lemuel Shattuck recommended standardized nomenclature for cause of disease and death.

4. History…. 1899: The UK began compulsory notification of selected infectious diseases. 1925: All states were reporting weekly to the United States Public Health Service on the occurrence of selected diseases. 1967: Global campaign to eradicate smallpox by achieving high vaccination level, reporting network was firmly established in most countries. 1973: The goal of eradication neared, a systematic house-to-house search for cases was established in India and subsequently used widely in Pakistan and Bangladesh. 1981:National surveillance was begun in the US and other countries. Even before the aetiological agent, HIV, was identified, surveillance data contributed to identifying modes of transmission, population groups at risk for infection. 1899: The UK began compulsory notification of selected infectious diseases. 1925: All states were reporting weekly to the United States Public Health Service on the occurrence of selected diseases. 1967: Global campaign to eradicate smallpox by achieving high vaccination level, reporting network was firmly established in most countries. 1973: The goal of eradication neared, a systematic house-to-house search for cases was established in India and subsequently used widely in Pakistan and Bangladesh. 1981:National surveillance was begun in the US and other countries. Even before the aetiological agent, HIV, was identified, surveillance data contributed to identifying modes of transmission, population groups at risk for infection. 4

5. Surveillance ‘The continued watchfulness over the distribution and trends of incidence through the systematic collection, consolidation, and evaluation of morbidity and mortality reports and other relevant data' together with timely and regular dissemination to those who 'need to know‘. Langmuir(1963) ‘The systematic collection and use of epidemiological information for the planning, implementation, and assessment of disease control; in short, surveillance implied 'information for action‘. WHO(1968) ‘The continued watchfulness over the distribution and trends of incidence through the systematic collection, consolidation, and evaluation of morbidity and mortality reports and other relevant data' together with timely and regular dissemination to those who 'need to know‘. Langmuir(1963) ‘The systematic collection and use of epidemiological information for the planning, implementation, and assessment of disease control; in short, surveillance implied 'information for action‘. WHO(1968) 5

6. Types of surveillance Active surveillance Passive surveillance Sentinel surveillance Categorical surveillance Integrated surveillance Syndromic surveillance Behavioral risk factor surveillance system (BRFSS) Public health surveillance Active surveillance Passive surveillance Sentinel surveillance Categorical surveillance Integrated surveillance Syndromic surveillance Behavioral risk factor surveillance system (BRFSS) Public health surveillance 6

7. Active surveillance: Health department contacts health care providers or laboratories requesting information about conditions or diseases to identify possible cases.  Requires more resources than passive surveillance  Useful when important to identify all cases  It is often used if an outbreak has begun or is suspected to keep close track of the number of cases. Community health workers may be asked to do active case finding in the community in order to detect those patients who may not come to health facilities for treatment. Passive surveillance: Local and state health departments rely on health care providers or laboratories to report cases of disease.  Primary advantage is efficiency: simple and requires relatively few resources  Disadvantage is possibility of incomplete data due to underreporting  Majority of public health surveillance systems are passive Active surveillance: Health department contacts health care providers or laboratories requesting information about conditions or diseases to identify possible cases.  Requires more resources than passive surveillance  Useful when important to identify all cases  It is often used if an outbreak has begun or is suspected to keep close track of the number of cases. Community health workers may be asked to do active case finding in the community in order to detect those patients who may not come to health facilities for treatment. Passive surveillance: Local and state health departments rely on health care providers or laboratories to report cases of disease.  Primary advantage is efficiency: simple and requires relatively few resources  Disadvantage is possibility of incomplete data due to underreporting  Majority of public health surveillance systems are passive 7

8. Sentinel Surveillance Used when high-quality data are needed about a particular disease that cannot be obtained through a passive system. Selected reporting units, with a high probability of seeing cases of the disease in question, good laboratory facilities and experienced well-qualified staff, identify and notify on certain diseases. Involves only a limited network of carefully selected reporting sites. Data used to signal trends, identify outbreaks and monitor the burden of disease in a community, providing a rapid, economical alternative to other surveillance methods. Used when high-quality data are needed about a particular disease that cannot be obtained through a passive system. Selected reporting units, with a high probability of seeing cases of the disease in question, good laboratory facilities and experienced well-qualified staff, identify and notify on certain diseases. Involves only a limited network of carefully selected reporting sites. Data used to signal trends, identify outbreaks and monitor the burden of disease in a community, providing a rapid, economical alternative to other surveillance methods. 8

9. Categorical surveillance An active or passive system that focuses on one or more diseases or behaviors of interest to an intervention program. These systems are useful for program managers. However, they may be inefficient at the district or local level, at which staff may need to fill out multiple forms on the same patient (that is, the HIV program, the tuberculosis program, the sexually transmitted infections program, and the Routine Health Information System). Integrated surveillance A combination of active and passive systems using a single infrastructure that gathers information about multiple diseases or behaviors of interest to several intervention programs (for example, a health facility–based system may gather information on multiple infectious diseases and injuries). Categorical surveillance An active or passive system that focuses on one or more diseases or behaviors of interest to an intervention program. These systems are useful for program managers. However, they may be inefficient at the district or local level, at which staff may need to fill out multiple forms on the same patient (that is, the HIV program, the tuberculosis program, the sexually transmitted infections program, and the Routine Health Information System). Integrated surveillance A combination of active and passive systems using a single infrastructure that gathers information about multiple diseases or behaviors of interest to several intervention programs (for example, a health facility–based system may gather information on multiple infectious diseases and injuries). 9

10. Behavioral risk factor surveillance system (BRFSS) An active system of repeated surveys that measure behaviors that are known to cause disease or injury (for example, tobacco or alcohol use, unprotected sex, or lack of physical exercise). Because the aim of many intervention program strategies is to prevent disease by preventing unhealthy behavior. These surveys provide a direct measure of their effect in the population, often long before the anticipated health effects are expected. These surveys are useful for providing timely measures of program effectiveness for both communicable and non communicable disease interventions. Behavioral risk factor surveillance system (BRFSS) An active system of repeated surveys that measure behaviors that are known to cause disease or injury (for example, tobacco or alcohol use, unprotected sex, or lack of physical exercise). Because the aim of many intervention program strategies is to prevent disease by preventing unhealthy behavior. These surveys provide a direct measure of their effect in the population, often long before the anticipated health effects are expected. These surveys are useful for providing timely measures of program effectiveness for both communicable and non communicable disease interventions. 10

11. Public health surveillance Public health surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of health data. Public health agencies use surveillance data to describe and monitor health events in their jurisdictions, set priorities, and to assist in the planning, implementation, and evaluation of public health interventions and programs. Public health surveillance is the ongoing systematic collection, analysis, interpretation, and dissemination of health data. Public health agencies use surveillance data to describe and monitor health events in their jurisdictions, set priorities, and to assist in the planning, implementation, and evaluation of public health interventions and programs. 11

12. Public Health Surveillance (Introduction) Public health surveillance is the mechanism that public health agencies use to monitor the health of their communities. Its purpose is to provide a factual basis from which agencies can appropriately set priorities, plan programs, and take actions to promote and protect the public’s health. A systematic process of reporting of various diseases of public health importance, as and when, and where, they occur, to a designated agency responsible for taking effective interventional steps. Public health surveillance is the mechanism that public health agencies use to monitor the health of their communities. Its purpose is to provide a factual basis from which agencies can appropriately set priorities, plan programs, and take actions to promote and protect the public’s health. A systematic process of reporting of various diseases of public health importance, as and when, and where, they occur, to a designated agency responsible for taking effective interventional steps. 12

13. Introduction.... Its success depend upon 3R's i.e.,  The quality of diagnosis Recognition  The timeliness and completeness of Reporting,  Analysis and effectiveness feedback Response. Disease surveillance has long been recognized as an important tool for measuring the disease burden, studying morbidity and mortality trends and early detection of outbreaks for instituting effective control measures in a timely manner. Its success depend upon 3R's i.e.,  The quality of diagnosis Recognition  The timeliness and completeness of Reporting,  Analysis and effectiveness feedback Response. Disease surveillance has long been recognized as an important tool for measuring the disease burden, studying morbidity and mortality trends and early detection of outbreaks for instituting effective control measures in a timely manner. 13

14. Conceptual framework for public health surveillance 14 † Vital registration, cancer registries, and exposure registries § Medical and laboratory records, pharmacy records. ¶ Weather, climate change, and pollution. ** Criminal justice information and census. Source: ( Porta MA, Dictionary of Epidemiology, 5th Ed., Oxford University Press, 2008). † Vital registration, cancer registries, and exposure registries § Medical and laboratory records, pharmacy records. ¶ Weather, climate change, and pollution. ** Criminal justice information and census. Source: ( Porta MA, Dictionary of Epidemiology, 5th Ed., Oxford University Press, 2008).

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17. Purposes of Public Health Surveillance To define public health priorities To characterize disease pattern by time, place, person To detect epidemics To suggest hypothesis To identify cases for epidemiological research To evaluate prevention and control program To facilitate planning, including projection of future trends and health care needs. To define public health priorities To characterize disease pattern by time, place, person To detect epidemics To suggest hypothesis To identify cases for epidemiological research To evaluate prevention and control program To facilitate planning, including projection of future trends and health care needs. 17

18. Health surveillance in India Health problems are predominantly due to communicable diseases and non communicable diseases. 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. Health problems are predominantly due to communicable diseases and non communicable diseases. 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. 18

19. Following plague outbreak in 1994, Government of India constituted  Technical Advisory Committee on Plague (1994),  Committee to formulate a comprehensive National Programme on Sanitation and Environment Hygiene on the lines of Technology Mission (1995)  Expert Committee on Public Health System (1996). Thereafter, National Apical Advisory Committee (NAAC) under the chairmanship of Union Health Secretary in 1999 Following plague outbreak in 1994, Government of India constituted  Technical Advisory Committee on Plague (1994),  Committee to formulate a comprehensive National Programme on Sanitation and Environment Hygiene on the lines of Technology Mission (1995)  Expert Committee on Public Health System (1996). Thereafter, National Apical Advisory Committee (NAAC) under the chairmanship of Union Health Secretary in 1999 19

20. NATIONAL SURVEILLANCE PROGRAMME FOR COMMUNICABLE DISEASES (NSPCD) Government of India launched National Surveillance Programme for Communicable Diseases (NSPCD) as a pilot project in 1997-98 with the overall goal of improving the health status of the people. Objectives 1. Capacity building at the state and district for early identification of outbreaks of communicable diseases, and 2. Appropriate and timely response to the outbreaks of communicable diseases. Government of India launched National Surveillance Programme for Communicable Diseases (NSPCD) as a pilot project in 1997-98 with the overall goal of improving the health status of the people. Objectives 1. Capacity building at the state and district for early identification of outbreaks of communicable diseases, and 2. Appropriate and timely response to the outbreaks of communicable diseases. 20

21. Programme Activities 1. Surveillance system is strengthened through training of medical and paramedical personnel 2. Dissemination of technical information and guidelines. 3. Up gradation of laboratories. 4. Modernization of communicable and data processing systems, and 5. IEC activities to promote community participation in the prevention and control of outbreaks. Programme Activities 1. Surveillance system is strengthened through training of medical and paramedical personnel 2. Dissemination of technical information and guidelines. 3. Up gradation of laboratories. 4. Modernization of communicable and data processing systems, and 5. IEC activities to promote community participation in the prevention and control of outbreaks. 21

22. Prioritizing Diseases for Surveillance 1. Acute Flaccid Paralysis* 2. AIDS* 3. Chicken pox 4. Cholera like diarrhoea 5. Diphtheria 6. Dysentery 7. Encephalitis 8. Fever syndrome more than 6 days 9. Hemorrhagic fever 10. Hepatitis 11. Herpes zoster 12. Leprosy* 13. Malaria: falciparum and vivax* 14. Measles 15. Meningitis: non-pyogenic and pyogenic 16. Mumps 17. Rabies 18. Rheumatic fever 19. Tetanus neonatorum* 20. Tetanus in older age 21. TB in older age and pulmonary* 22. Whooping cough 23. Any other of public health importance 22

23. The District Epidemiology Cell The District Epidemiology Cell reports weekly summary data on diseases and interventions to the State Epidemiology Centre, which collect all district data and pass on monthly summaries to the National Institute of Communicable Diseases (NICD). The NICD has been expanded and strengthened to act as the National Apical Laboratory in support of the state level laboratories. Regional laboratories have been established as an intermediate level between the District cells and State and Centre. Headed by one senior officer as the District Epidemiology Officer, One Medical Officer and 5 field workers per 2 million. Data should be analyzed on a weekly basis and weekly summary statistics will be forwarded to the State Epidemiology unit. Responsible for defining and designing interventions. The District Epidemiology Cell reports weekly summary data on diseases and interventions to the State Epidemiology Centre, which collect all district data and pass on monthly summaries to the National Institute of Communicable Diseases (NICD). The NICD has been expanded and strengthened to act as the National Apical Laboratory in support of the state level laboratories. Regional laboratories have been established as an intermediate level between the District cells and State and Centre. Headed by one senior officer as the District Epidemiology Officer, One Medical Officer and 5 field workers per 2 million. Data should be analyzed on a weekly basis and weekly summary statistics will be forwarded to the State Epidemiology unit. Responsible for defining and designing interventions. 23

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26. INTEGRATED DISEASE SURVEILLANCE PROGRAM (IDSP): Launched by Union Minister of Health and Family Welfare on 8th November 2004 for establishing decentralized surveillance covering communicable and non communicable diseases. IDSP was intended to be the back bone of public health programs in the country. IDSP is a decentralized, state based surveillance programme. IDSP helps..... To detect early warning signals of impending outbreaks To initiate effective response in a timely manner. To provide essential data to monitor progress of ongoing diseases Helps to allocate health resources more efficiently. Help to identify areas of health priority where more inputs are necessary. Launched by Union Minister of Health and Family Welfare on 8th November 2004 for establishing decentralized surveillance covering communicable and non communicable diseases. IDSP was intended to be the back bone of public health programs in the country. IDSP is a decentralized, state based surveillance programme. IDSP helps..... To detect early warning signals of impending outbreaks To initiate effective response in a timely manner. To provide essential data to monitor progress of ongoing diseases Helps to allocate health resources more efficiently. Help to identify areas of health priority where more inputs are necessary. 26

27. Objectives To establish a decentralized district based system of surveillance for communicable and non-communicable diseases, so that timely and effective public health actions can be initiated in response to health changes in the urban and rural areas. To integrate existing surveillance activities to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders, so that valid data is available for health decision making in the district, state and national levels. To establish a decentralized district based system of surveillance for communicable and non-communicable diseases, so that timely and effective public health actions can be initiated in response to health changes in the urban and rural areas. To integrate existing surveillance activities to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders, so that valid data is available for health decision making in the district, state and national levels.

28. IDSP 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 Phase III (2006-07) – UP, Bihar, J&K, Punjab, Jharkhand, Arunachal, Assam, Sikkim, A&N Island, D&N Haveli, Daman & Diu, Lakshadweep 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 Phase III (2006-07) – UP, Bihar, J&K, Punjab, Jharkhand, Arunachal, Assam, Sikkim, A&N Island, D&N Haveli, Daman & Diu, Lakshadweep 28

29. Components Integrating & decentralizing disease surveillance & response mechanisms Strengthening Public Health Laboratories Using Information Technology and Networking in disease surveillance Human Resource Development Integrating & decentralizing disease surveillance & response mechanisms Strengthening Public Health Laboratories Using Information Technology and Networking in disease surveillance Human Resource Development 29

30. Classification of surveillance in IDSP Syndromic  Diagnosis made on the basis of clinical pattern by paramedical personnel and members of community Presumptive  Diagnosis is made on typical history and clinical examination by medical officers Confirmed  Clinical diagnosis confirmed by appropriate laboratory identification Syndromic  Diagnosis made on the basis of clinical pattern by paramedical personnel and members of community Presumptive  Diagnosis is made on typical history and clinical examination by medical officers Confirmed  Clinical diagnosis confirmed by appropriate laboratory identification 30

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

32. Key Massages Public health surveillance has historically galvanized prevention and control program ranging from smallpox eradication and immunization campaigns for childhood diseases to programs to prevent HIV infection and AIDS. Surveillance has also taken on increased visibility and importance in evaluating and directing prevention and control efforts for non-infectious diseases and conditions. Surveillance systems represent information loops, with data flowing from local to central agencies and back. Surveillance provides a stimulus to keep prevention and control activities moving rapidly and in the right direction, guiding the response to individual cases as well as public policy. Public health surveillance has historically galvanized prevention and control program ranging from smallpox eradication and immunization campaigns for childhood diseases to programs to prevent HIV infection and AIDS. Surveillance has also taken on increased visibility and importance in evaluating and directing prevention and control efforts for non-infectious diseases and conditions. Surveillance systems represent information loops, with data flowing from local to central agencies and back. Surveillance provides a stimulus to keep prevention and control activities moving rapidly and in the right direction, guiding the response to individual cases as well as public policy. 32

33. Key Massages Effective public health interventions depend upon a continuing and reliable source of information. The data must be timely and representative of the population; they must be analyzed and interpreted with feedback to the reporters and dissemination to those formulating and implementing public health policy. Resources necessary for the maintenance of the surveillance systems and for their regular evaluation should be allocated, balancing needs for data to direct prevention activities with needs for resources to implement those activities. Effective public health interventions depend upon a continuing and reliable source of information. The data must be timely and representative of the population; they must be analyzed and interpreted with feedback to the reporters and dissemination to those formulating and implementing public health policy. Resources necessary for the maintenance of the surveillance systems and for their regular evaluation should be allocated, balancing needs for data to direct prevention activities with needs for resources to implement those activities. 33

34. References Report MW. CDC ’ s Vision for Public Health Surveillance in the 21 st Century. 2012;61. Nsubuga P, White ME, Thacker SB, Anderson MA, Blount SB, Broome C V, et al. Chapter 53 Public Health Surveillance : A Tool for Targeting and Monitoring Interventions. 2016;(Dc):1– 36. Oxford Textbook of Public Health 4th Edition (21 March 2002): By Roger Detels,James McEwen, Robert Beaglehole,Heizo Tanaka By Oxford University Press List US. Lesson 5 Public Health Surveillance Introduction to Public Health Surveillance. National Surveillance Programme for Communicable Diseases (NSPCD).www.nihfw.nic.in Integrated Disease Surveillance Program (IDSP).www.idsp.nic.in Report MW. CDC ’ s Vision for Public Health Surveillance in the 21 st Century. 2012;61. Nsubuga P, White ME, Thacker SB, Anderson MA, Blount SB, Broome C V, et al. Chapter 53 Public Health Surveillance : A Tool for Targeting and Monitoring Interventions. 2016;(Dc):1– 36. Oxford Textbook of Public Health 4th Edition (21 March 2002): By Roger Detels,James McEwen, Robert Beaglehole,Heizo Tanaka By Oxford University Press List US. Lesson 5 Public Health Surveillance Introduction to Public Health Surveillance. National Surveillance Programme for Communicable Diseases (NSPCD).www.nihfw.nic.in Integrated Disease Surveillance Program (IDSP).www.idsp.nic.in 34