Public Health 101 Series

Introduction to Public Health

Surveillance
Radian Ilmaskal
SKM, MPH
STIKES Alifah Padang

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Center for Surveillance, Epidemiology, and Laboratory Services

Division of Scientific Education and Professional Development
 Course Topics
Introduction to Public Health Surveillance

1. A Public Health Approach

2. What is Public Health Surveillance?
3. Public Health Surveillance Role and Uses
4. Public Health Surveillance Legal Basis
5. Public Health Surveillance Types and
Attributes
6. Public Health Surveillance Process

2
 Learning Objectives

By the end of this session, you will be able to

• define public health surveillance
• describe the goal of public health surveillance
• describe the uses of a public health surveillance system
• recognize the legal basis for public health surveillance in the United
States
• compare active and passive public health surveillance
• identify sources of data commonly used for public health surveillance
• describe the public health surveillance process

3
 Topic 1
A Public Health Approach

4
 A Public Health Approach

Risk Factor Intervention

Surveillance Implementation
Identification Evaluation

5
Public Health Core Sciences

6
 Topic 2
What is Public Health
Surveillance?

7
 Public Health Surveillance Defined

The ongoing, systematic collection,

analysis, and interpretation of health-related
data essential to planning, implementation,
and evaluation of public health practice,
closely integrated with the timely
dissemination of these data to those
responsible for prevention and control

Adapted from: Thacker SB, Birkhead GS. Surveillance. In: Gregg, MB, ed. Field epidemiology. Oxford, England: Oxford University Press; 2008.
8
Public Health Surveillance Keywords

systematic
ongoing
collection
analysis
interpretation
dissemination
health-related data
linked to public health practice 9
 Goal of Public Health Surveillance

Provide information that can be used for health action by

public health personnel, government leaders, and the

public to guide public health policy and programs

Smith PF, Hadler JL, Stanbury M, et al. Blueprint version 2.0: updating public health surveillance for the 21st century. J Public Health Manag Pract
2013;19:231–9. 10
 Knowledge Check

Public Health Surveillance is the ________, __________

collection, analysis, and interpretation of health-related data.

A. systemic, short-term

B. ongoing, systemic

C. ongoing, systematic

D. methodical, ongoing

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 Knowledge Check

What is the goal of public health surveillance?

A. To give public health personnel policies to regulate

B. To provide information to be used for public

health action

C. To guide Congress in enacting public health laws

D. To keep the public aware of new diseases

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 Topic 3
Public Health Surveillance
Role and Uses

13
 Uses of Public Health Surveillance

• Identify patients and their contacts for treatment and intervention

• Detect epidemics, health problems, changes in health behaviors
• Estimate magnitude and scope of health problems
• Measure trends and characterize disease
• Monitor changes in infectious and environmental agents
• Assess effectiveness of programs and control measures
• Develop hypotheses and stimulate research

14
 Public Health Headlines
Whooping Cough Kills Five in California;
State Declares an Epidemic

New CDC Report Shows Adult Obesity

Growing or Holding Steady in All States

Increase Seen in Deaths from

Pneumonia and Flu

Number of Rare E. Coli Cases

In U.S. Rose Last Year

Percentage of New Yorkers Lighting Up

is Down to 14%
15
 Number of Rare E. Coli Cases
In U.S. Rose Last Year

Neuman W. Number of Rare E. Coli Cases In U.S. Rose Last Year. The New York Times. June 7, 2011. http://www.nytimes.com.
Accessed July 8, 2014. 16
 Knowledge Check
Identify the surveillance uses that can be linked to
the New York Times E. coli article.

A. Measure trends of a particular disease

B. Estimate the magnitude of the problem
C. Monitor changes in infectious and environmental
agents
D. Assess effectiveness of programs and control
measures
E. All of the above

17
 Topic 4
Public Health Surveillance
Legal Basis

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Legal Authority for Conducting
Public Health Surveillance

States have authority based on

the U.S. Constitution
• General welfare clause
• Interstate commerce clause

CDC responds when

• disease or condition has interstate
implications
• invited by a state

19
 State-Based Notifiable Disease
Surveillance Systems
• Mandated by state law or regulation
• Health care providers, hospitals, and laboratories are required to
report cases to the local health department (LHD)
• The LHD is usually responsible for case investigation and action
• The LHD forwards the disease report to the state health
department
• The state health department assists the LHD as needed

20
 Knowledge Check

The purpose and legal basis for public health surveillance is

granted by which U.S. document?

A. Bill of Rights

B. Declaration of Independence

C. U.S. Constitution

D. 1812 Treaty of Public Health

21
 Knowledge Check

CDC must be invited by a state before conducting public health

surveillance.

A. True

B. False

22
 Topic 5
Public Health Surveillance
Types and Attributes

23
 Types of Public Health Surveillance

Passive Surveillance Active Surveillance

• Diseases are reported • Health agencies contact health
by health care providers providers seeking reports

• Simple and inexpensive • Ensures more complete reporting

of conditions
• Limited by incompleteness
of reporting and variability • Used in conjunction
of quality with specific epidemiologic
investigation

24
 Other Types of Public Health Surveillance

Sentinel Surveillance

Reporting of health events by health professionals who are

selected to represent a geographic area or a specific reporting
group
Can be active or passive

Syndromic Surveillance

Focuses on one or more symptoms rather than a physician-

diagnosed or laboratory-confirmed disease

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 Surveillance System Attributes
Attribute Question It Answers
How useful is the system in accomplishing its
Usefulness objectives?

How reliable are the available data? How

complete and accurate are data fields in the
Data quality reports received by the system?

Timeliness How quickly are reports received?

How quickly can the system adapt to changes?
Flexibility

Simplicity How easy is the system’s operation?

26
 Surveillance System Attributes
Attribute Question It Answers
Does the surveillance system work well?
Stability Does it break down often?

How well does it capture the intended cases?

Sensitivity

Predictive value How many of the reported cases meet the

positive case definition?
How good is the system at representing the
Representativeness population under surveillance?

Acceptability How easy is the system’s operation?

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 Knowledge Check

The New York State Department of Health contacts the health

providers in District A every Friday to obtain the number of
patients examined with Influenza. What type of surveillance is
this?

A. Passive

B. Active

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 Topic 6
Public Health Surveillance
Process

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 Surveillance Process

Data Collection
Before collecting data, decide
on the overarching goal
Data Analysis of the system
Data
Interpretation

Data
Dissemination

Link to Action

30
 Data Sources for Public Health Surveillance

• Reported diseases or syndromes

• Electronic health records (e.g., hospital discharge data)
• Vital records (e.g., birth and death certificates)
• Registries (e.g., cancer, immunization)
• Surveys (e.g., National Health and Nutrition Examination
Survey [NHANES])

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Nationally Notifiable Disease
Surveillance System (NNDSS)

Many diseases on a state list

are also nationally
notifiable

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 Internationally Notifiable Diseases

Reporting to WHO is required for cases of

• Smallpox
• Poliomyelitis (wild type)
• Human influenza caused by any
new subtype
• Severe acute respiratory
syndrome (SARS)

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 Surveillance Data Analysis

Data Collection
• Who will analyze the data?
Data Analysis • What methodology will they use?
• How often will they analyze the
Data data?
Interpretation

Data
Dissemination

Link to Action

34
 Patients Hospitalized with West Nile
Virus Infection, by Week, New York, 1999

Week of illness onset

Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York City area in 1999.
N Engl J Med. 2001;344:1807–14. 35
 Surveillance Data Analysis by Place
Laboratory-Confirmed WNV Human Cases — August–September 1999

North Queens
Serosurvey Area

Map Courtesy of the New York City Department of Health and Mental Hygiene
36
 Data Analysis by Person
Do you notice any patterns in the rates?
Demographics for Persons Hospitalized for WNV and Population Rates of Infection
Rate of Infection per
Characteristic No. of Patients (%) Population at Risk Million Population
Age (years)
0–19 2 (3) 2,324,081 0.9
20–29 1 (2) 1,553,981 0.6
30–39 3 (5) 1,549,111 1.9
40–49 1 (2) 1,177,190 0.8
50–59 9 (15) 867,331 10.4
60–69 12 (22) 814,838 16.0
70–79 18 (31) 534,785 33.7
≥80 12 (20) 281,054 42.7
Age category (years)
≥50 52 (88) 2,498,008 20.8
<50 7 (12) 6,604,363 1.1
Sex
Male 31 (53) 4,289,988 7.2
Female 28 (47) 4,812,383 5.8
Race
White 41 (69) 5,983,901 6.9
Nonwhite 9 (15) 3,118,470 2.9
Unknown 9 (15) -- --
Borough or county of residence
New York City
Brooklyn (Kings) 3 (5) 2,300,664 1.3
Bronx 9 (15) 1,203,789 7.5
Manhattan 1 (2) 1,487,536 0.7
Queens 32 (54) 1,951,599 16.4
Staten Island (Richmond) 0 379,999 0.0
New York State
Nassau 6 (10) 1,287,348 4.7
Westchester 8 (14) 847,866 9.1

Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York City area in 1999. N Engl J Med. 37
2001;344:1807–14.
 Surveillance Data Interpretation

Data
Collection
Data interpretation is
Data Analysis closely coupled with
data analysis
Data
Interpretation
Data
Dissemination

Link to Action

38
 What Can Account for an
Apparent
Number ofIncrease in Cases?
Rare E. Coli Cases
In U.S. Rose Last Year

Neuman, W. Rare E. Coli Cases Rose In the U.S. Last Year. New York Times June 7, 2011. http://www.nytimes.com. Accessed
July 9, 2014. 39
 Data Dissemination

Data Collection • Health agency newsletters,

bulletins, or alerts

Data Analysis • Surveillance summaries and

Data
reports
Interpretation
• Medical and epidemiologic journal
Data
articles
Dissemination

Link to Action • Press releases and social media

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 Data Dissemination Target Audiences

• Public health practitioners

• Clinicians and other health care providers
• Policy and other decision makers
• Community organizations
• The general public

41
 Surveillance Link to Action

Data Collection

Public health surveillance

Data Analysis should always have a
Data
link to action
Interpretation

Data
Dissemination

Link to Action

42
 Link to Action
Monitor trends and patterns in disease, risk factors, and agents

Pertussis (Whooping Cough) Cases, by Year — United States, 1922–2000

Source: Centers for Disease Control and Prevention (CDC). National Notifiable Diseases Surveillance System and Supplemental
Pertussis Surveillance System and 1922-1949, passive reports to the US Public Health Service. Atlanta, GA: US Department of
Health and Human Services, CDC. Available at: http://www.cdc.gov/pertussis/images/incidence-graph.jpg. 43
 Knowledge Check

Choose the option that is NOT a part of the public health

surveillance process.

A. Data dissemination

B. Data storage
C. Link to action
D. Data collection

44
 Knowledge Check
In data interpretation, by identifying the ___________,
________, and _____________, you can more easily determine
how and why the health event occurred.

A. disease, risk, occurrence

B. person, protocol, risk

C. person, place, time

D. risk, protocol, disease

45
 Knowledge Check

Choose the option that is NOT a source of data used for public
health surveillance.

A. Administrative data systems

B. Vital records
C. Newspaper articles
D. Disease notifications

46
 Public Health Surveillance-Based Action
• Describe the burden of or potential for disease

• Monitor trends and patterns in disease, risk factors, and agents

• Detect sudden changes in disease occurrence and distribution

• Provide data for programs, policies, and priorities

• Evaluate prevention and control efforts

47
 “The reason for collecting, analyzing,
and disseminating information on a
disease is to control that disease.
Collection and analysis should not be
allowed to consume resources if
action does not follow.”

—William Foege, 1976

Photo: Kay Hinton, Emory University

Foege WH, Hogan RC, Newton LH. Surveillance projects for selected diseases. Int J Epidemiol 1976;5:29–37. 48
 Course Summary
During this session, you learned to
• define public health surveillance
• describe the goal of public health surveillance
• describe the uses of public health surveillance system
• recognize the legal basis for public health surveillance
in the United States
• compare active and passive public health surveillance
• identify sources of data commonly used for public health surveillance
• describe the public health surveillance process

49
QUESTIONS?

50
 Resources and Additional Reading
• Smith PF, Hadler JL, Stanbury M, et al. Blueprint version 2.0: updating public health
surveillance for the 21st century. J Public Health Manag Pract 2013;19:231–9.
• Centers for Disease Control and Prevention. CDC’s vision for public health surveillance in the
21st century. Morb Mortal Wkly Rep 2012;61(Suppl, July 27, 2012):1–40.
• Centers for Disease Control and Prevention (CDC). Principles of epidemiology in public health
practice [Self-Study Course]. 3rd ed. Atlanta, GA: US Department of Health and Human
Services, CDC; 2006. http://www.cdc.gov/osels/scientific_edu/ss1978/SS1978.pdf.
• Lee LM, Teutsch SM, Thacker SB, St. Louis M, Eds. Principles and practice of public health
surveillance. 3rd ed. Oxford, England: Oxford University Press; 2010.
• Thacker SB, Birkhead GS. Surveillance. In: Gregg, MB, ed. Field epidemiology. Oxford,
England: Oxford University Press; 2008.
• Langmuir AD. The surveillance of communicable diseases of national importance. New Engl J
Med 1963;258:182–92.
• Foege WH, Hogan RC, Newton LH. Surveillance projects for selected diseases. Int J Epidemiol
1976;5:29–37.

51
 Resources and Additional Reading
• Centers for Disease Control and Prevention. Updated guidelines for evaluating public health
surveillance systems: recommendations from the Guidelines Working Group. MMWR
Recommend Rep 2001;50(No. RR-13).
• Centers for Disease Control and Prevention (CDC). Surveillance resource center. Atlanta, GA:
US Department of Health and Human Services, CDC; 2013.
http://www.cdc.gov/surveillancepractice/.
• Nash D, Mostashari F, Fine A, et al. Outbreak of West Nile virus infection in the New York
City area in 1999. N Engl J Med. 2001;344:1807–14.
• Török TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salmonellosis caused by
intentional contamination of restaurant salad bars. JAMA 1997;278:389–95.
• Kim M, Berger D, Matte T. Diabetes in New York City: public health burden and disparities.
New York: New York City Department of Health and Mental Hygiene; 2006.
http://www.nyc.gov/html/doh/downloads/pdf/epi/diabetes_chart_book.pdf.
• Swerdlow DL, Woodruff BA, Brady RC, et al. A waterborne outbreak in Missouri of
Escherichia coli O157:H7 associated with bloody diarrhea and death. Ann Intern Med
1992;117:812–9.

52
BONUS SLIDES

53
 Link to Action
Provide data for programs, policies, and priorities
% Reporting diabetes

1994–95 1996–97 1998–99 2000–01 2002 2003 2004

Year
Kim M, Berger D, Matte T. Diabetes in New York City: public health burden and disparities. New York: New York City Department of
Health and Mental Hygiene; 2006. http://www.nyc.gov/html/doh/downloads/pdf/epi/diabetes_chart_book.pdf. 54
 Link to Action
Evaluate prevention and control efforts

Water Boil-water
system order
No. of cases

flushed

Date of onset

Swerdlow DL, Woodruff BA, Brady RC, et al. A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody
diarrhea and death. Ann Intern Med 1992;117:812–9. 55
 Link to Action
Evaluate prevention and control efforts (continued)

Boil-water Chlorine
Water order added
system
flushed
No. of cases

Date of onset

Swerdlow DL, Woodruff BA, Brady RC, et al. A waterborne outbreak in Missouri of Escherichia coli O157:H7 associated with bloody
diarrhea and death. Ann Intern Med 1992;117:812–9. 56
 Disclaimers
Links provided in this course to nonfederal organizations are provided solely as a service to our
users. These links do not constitute an endorsement of these organizations nor their programs by
the Centers for Disease Control and Prevention (CDC) or the federal government, and none should
be inferred. CDC is not responsible for the content contained at these sites.

Use of trade names and commercial sources is for identification only and does not imply
endorsement by the Division of Scientific Education and Professional Development, Center for
Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention,
the Public Health Service, or the U.S. Department of Health and Human Services.

The findings and conclusions in this course are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.

57
For more information, please contact the Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: http://www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or http://www.cdc.gov/info

The findings and conclusions in this course are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.

Center for Surveillance, Epidemiology, and Laboratory Services

Division of Scientific Education and Professional Development