University Of Liberia

T.J.R Faulkner College of Science & technology and School of Environmental Studies & Climate Change
Fendell Campus, Louisiana, Fendell Campus
BSPH 211(Fundamental of Public Health Surveillance) Sec 4&5
Semester I
Department: Public Health

Instructor: T. Emmanuel Glasco

Credit Hour: 3 Hour
Class time: Monday Wednesday and Friday
Contact Hours: Only on class days
Mobile #: 0777194205
Email: [email protected]

Catalog Description:
Introduces students to public health surveillance, a critical public function for understanding and
monitoring population health. Covers the theory, data collection methods, data analysis tools,
and presentation strategies for the systematic, ongoing study and interpretation of population
health data to inform public health practice planning, implementation, and evaluation. Students
identify the many types of surveillance and how they are used in various health related
circumstances. Practical experiences involve the development of data collection tools and
application in practice. Real-world surveillance data is used to demonstrate analysis
methodologies and how surveillance data should be presented to various audiences.
Required Materials : Principles and Practice of public health surveillance, Introduction to public
health surveillance, Transforming Public health surveillance

Objectives:
Upon completion of this course, the student will be able to:
1. Define and understand Public Health surveillance.
2. Explain the History/Evolution of Public health Surveillance.
3. Discuss the main function of public health surveillance.
4. Describe different designs in basic public health surveillance including active and passive
surveillance programs.
5. Describe sources of data that can be used for public health surveillance.
Method of Instructions
BSPH 211 Course will be conducted through lectures, discussion, brainstorming, assignments,
group work, and presentations.
Responsibilities of Students:
students will be responsible to do the following: -
 Establish a personal email account
 Send class related work to only [email protected]
 Attend all classes.
 Participate in the classroom activities.
 Do all assignments.
 Do all quizzes and Exams.
 Do class presentations.
Method of Evaluation:
Attendance: 5%
Assignments: 10%
Presentations: 15%
Midterm: 30%
Final Exam: 40%
100%

Evaluation
Letter Grades and Equivalents
A =90-100%
B =80-89
C =70-79
D =60-69
F = Below 60
I = Lack of Mid-term grade or final exam grade

Course Content

Duration/Week Presentation Topics

1-3 History/Evolution of Public Health Surveillance
a. Discuss the beginnings of public health Surveillance.
b. Discuss the advances Of Public Health Surveillance
c. Discuss Reportable diseases.
d. Discuss the advances beyond Communicable Diseases
4-6 Introduction
a. A public approach
b. Definition of Public Health Surveillance and its concepts
d. Key terminology in relation to surveillance
d. Objectives/ Purpose of public health surveillance and its
components

7-8 a. Public Health surveillance Role and Uses

 b. Public Health Surveillance Types and attributes highlighting Active
and passive surveillance
c. Public Health Surveillance Process
Assignment/Pop Quiz

9 Group Presentation- Mid-term

10-12 Elements of public health Surveillance and Cycle
a. Elements (Timeliness, Representation, Sensitivity, and Specificity)
b. Cycle (collection, Integration or collation of data, analysis and
interpretation of data, Creation of surveillance products,
Dissemination of Products, action, and Evaluation
13-15 Surveillance Steps, Data sources, and uses in Public Health
a. Discuss the major considerations or steps in starting a
surveillance system.
b. Discuss sources of data that can be used for public health
surveillance.
c. Discuss the main uses of surveillance data.

16 Final Exam
History of Public health Surveillance
The idea of observing, recording, and collecting facts, analyzing them, and considering
reasonable courses of action stems from Hippocrates. The first real public health action that can
be related to surveillance probably occurred during the period of Bubonic plague, when public
health authorities boarded ships in the port near the Republic of Venice to prevent persons ill
with plague-like illness from disembarking. Before a large-scale organized system of
surveillance could be developed, however, certain prerequisites needed to be fulfilled. First, there
had to be some semblance of an organized health-care system in a stable government Second, a
classification system for disease and illness had to be established and accepted, which only
began to be functional in the 17th century with the work of Sydenham

Current concepts of public health surveillance evolve from public health activities developed to
control and prevent disease in the community. In the late Middle Ages, governments in Western
Europe assumed responsibilities for both health protection and health care of the population of
their towns and cities. In 1766, Johann Peter Frank advocated a more comprehensive form of
public health surveillance with the system of police medicine in Germany. It covered school
health, injury prevention, maternal and child health, and public water and sewage. In addition, he
delineated governmental measures to protect the public's health.

The roots of analysis of surveillance data can also be traced to the 16th century. In the 1680s,
von Leibnitz called for the establishment of a health council and the application of a numerical
analysis in mortality statistics to health planning. About the same time in London, John Graunt
published a book, Natural and Political Observations Made Upon the Bills of Mortality, in which
he attempted to define the basic laws of natality and mortality. In his work, Graunt developed
some fundamental principles of public health surveillance, including disease-specific death
counts, death rates, and the concept of disease patterns. A century later, in 1845, Thurnam
published the first extensive report of mental health statistics in London.

Two prominent names in the development of the concepts of public health surveillance activities
are Lemuel Shattuck and William Farr. Shattuck's 1850 report of the Massachusetts Sanitary
Commission was a landmark publication that related death, infant and maternal mortality, and
communicable diseases to living conditions. Shattuck recommended a decennial census,
standardization of nomenclature of causes of disease and death, and a collection of health data by
age, gender, occupation, socioeconomic level, and locality. He applied these concepts to program
activities in immunization, school health, smoking, and alcohol abuse, and introduced these
concepts into the teaching of preventive medicine.

William Farr (1807-1883) is recognized as one of the founders of modern concepts of

surveillance As superintendent of the statistical department of the Registrar General's office of
England and Wales from 1839 to 1879, Farr concentrated his efforts on collecting vital statistics,
on assembling and evaluating those data, and on reporting both to responsible health authorities
and to the general public.

Globally Public health surveillance has focused historically on infectious disease. Basic elements
of surveillance were found in Rhode Island (USA) in 1741, when the colony passed an act
requiring tavern keepers to report contagious among their patrons. Two years later, the colony
passed a broader law requiring the reporting of smallpox, yellow fever, and cholera.
disease among their patrons.
In Europe, compulsory reporting of infectious diseases began in Italy in 1881 and Great Britain
in 1890. In 1893, Michigan became the first U.S. jurisdiction to require the reporting of specific
infectious diseases. Also, in 1893, a law was enacted to provide for the collection of information
each week from state and municipal authorities throughout the United States (12). By 1901, all
state and municipal laws required notification (i.e., reporting) to local authorities of selected
communicable diseases such as smallpox, tuberculosis, and cholera. In 1914, PHS personnel
were appointed as collaborating epidemiologists to serve in state health departments to telegraph
weekly disease reports to the PHS.

In the United States, it was not until 1925, however, following markedly increased reporting
associated with the severe poliomyelitis epidemic in 1916 and the influenza pandemic in 1918-
1919, that all states had begun participating in national morbidity reporting. A national health
survey of U.S. citizens was first conducted in 1935. After a 1948 PHS study led to the revision of
morbidity reporting procedures, the National Office of Vital Statistics assumed the responsibility
for morbidity reporting. In the United States, the authority to require notification of cases of
disease resides in the respective state legislatures.

The Conference (now Council) of State and Territorial Epidemiologists (CSTE) was authorized
in 1951 by its parent body, the Association of State and Territorial Health Officials to determine
what diseases should be reported by states to the Public Health Service and to develop reporting
procedures. CSTE meets annually, and in collaboration with CDC, recommends to its constituent
members appropriate changes in morbidity reporting and surveillance, including what diseases
should be reported to CDC and published in the MMWR.

Advances of Public Health Surveillance

Until 1950, the term "surveillance" was restricted in public health practice to monitoring contacts
of persons with serious communicable diseases such as smallpox, to detect early symptoms so
that prompt isolation could be instituted. The critical demonstration of the importance of a
broader, population-based view of surveillance was made following the Francis Field Trial of
poliomyelitis vaccine in 1955. Within 2 weeks of the announcement of the results of the field
trial and initiation of a nationwide vaccination program, six cases of paralytic poliomyelitis were
reported through the notifiable-disease reporting system to state and local health departments in
the USA; this surveillance lead to an epidemiologic investigation, which revealed that these
children had received vaccine produced by a single manufacturer. Intensive surveillance and
appropriate epidemiologic investigations by federal, state, and local health departments found
141 vaccine associated cases of paralytic disease, 80 of which represented family contacts of
vaccinees. Daily surveillance reports were distributed by CDC to all persons involved in these
investigations. This national common-source epidemic was ultimately related to a particular
brand of vaccine that had been contaminated with live poliovirus.

In 1963, Langmuir limited use of the term "surveillance" to the collection, analysis, and
dissemination of data. This construct did not encompass direct responsibility for control
activities. In 1965, the Director General of the World Health Organization (WHO) established
the epidemiological surveillance unit in the Division of Communicable Diseases of WHO . The
Division Director, Karel Raska, defined surveillance much more broadly than Langmuir,
including "the epidemiological study of disease as a dynamic process." In the case of malaria, he
saw epidemiologic surveillance as encompassing control and prevention activities. Indeed, the
WHO definition of malaria surveillance included not only case detection, but also obtaining
blood films, drug treatment, epidemiologic investigation, and follow-up.
.
In 1968, the 21st World Health Assembly focused on national and global surveillance of
communicable diseases, applying the term to the diseases themselves rather than to the
monitoring of individuals with communicable disease. Following an invitation from the Director
General of WHO and with consultation from Raska, Langmuir developed a working paper and in
the year prior to the Assembly obtained comments from throughout the world on the concepts
and practices advocated in the paper. At the Assembly, with delegates from over 100 countries,
the working paper was endorsed, and discussions on the national and global surveillance of
communicable disease identified

three main features of surveillance that Langmuir had described in 1963

: a) the systematic collection of pertinent data, b) the orderly consolidation and evaluation
of these data, and c) the prompt dissemination of results to those who need to know--
particularly those in position to take action.

The 1968 World Health Assembly discussions reflected the broadened concepts of
epidemiologic surveillance" and addressed the application of the concept to public health
problems other than communicable disease. In addition, epidemiologic surveillance was said to
imply "...the responsibility of following up to see that effective action has been taken. ‘Since that
time, a wide variety of health events, such as childhood lead poisoning, leukemia, congenital
malformations, abortions, injuries, and behavioral risk factors have been placed under
surveillance.

In 1976, recognition of the breadth of surveillance activities throughout the world was made
evident by the fact that a special issue of the International Journal of Epidemiology was devoted
to surveillance.

The initial focus of public health surveillance principles and practices was on infectious diseases,
but today public health surveillance systems are use to monitor and forecast a broad range of
health determinants (eg, risk behaviors, health care services, socioeconomic factors) and
outcomes relevant to infectious diseases, injuries, chronic diseases, metal health, and
occupational and environmental health.

Beyond the monitoring of individual risk factors and outcomes, surveillance systems have also
been developed to monitor the presence of emergence, or eveolution of infectious agents in the
environment. Its use has expanded in relation to communicable diseases, for example to monitor
the impact of vaccination program on viral evolution in order to inform vaccine design and
maintain vaccine effectiveness. Data from surveillance are also used to forecast or predict future
trends in disease distribution.

A proactive population-based system of surveillance is establish only if the following are present
1. An organized health system and stable government
2. A classification system for disease and illness developed widely and accepted
3. Mathematical methods for statistical measurement

several activities have contributed to the advances and evolution of public health surveillance.
First, use of the computer- -particularly for the routine collection, analysis, and dissemination of
data on notifiable health conditions. Second the epidemiologic and statistical analysis of data.

Until recently, surveillance data were traditionally disseminated as written documents published
periodically by government agencies. While paper reports will continue to be produced, and
public health officials will continue to refine the use of print media, they are also beginning to
use electronic media for the dissemination of surveillance data. More effective use of the
electronic media, and all the other tools of communications, should facilitate the use of
surveillance data for public health practice.

NOTIFIABLE DISEASE AND RELATED REPORTING MECHANISMS

Reporting on notifiable diseases at the national level originated in the United States in 1878,
when Congress authorized the United States Public Health Service (PHS) to collect reports on
morbidity from cholera, smallpox, plague, and yellow fever, each of which was controlled
through quarantine measures. Although initially focused on foreign ports, authority for weekly
reporting was expanded in 1893 to include states and municipal authorities. To increase
uniformity, the Surgeon General was authorized in 1902 to provide forms for the collection,
completion, and publication of reports at the national level. The list of diseases for which
notification is recommended has changed over time, and, although there is overlap, the lists vary
from nation to nation.

In the United States, for instance, 47 infectious diseases were considered notifiable at the
national level in 1989 and were reported to CDC through the National Notifiable Disease
Surveillance System (NNDSS) . In at least one state, however, reporting was required for over
160 infectious diseases or related conditions. With the addition of Lyme disease and Hemophilus
influenza in 1991, 49 infectious diseases are currently notifiable at the national level in the
United States. Globally reporting is required for three quarantinable diseases--plague, cholera,
and yellow fever. Cases of these three diseases are also reported to the WHO by member
countries.

Although information on notifiable diseases is collated and published nationally, its

primary purpose is to direct local prevention and control programs. Information is generally
reported by clinicians to local or state health departments. Regulations governing notifiable
disease reporting are often quite specific regarding timeliness of reporting. For conditions in
which an immediate public health response is needed, notification by telephone is usually
mandated, either immediately or within 24 hours of a suspected case. Other conditions are
generally reported on a weekly basis after the diagnosis has been confirmed. For some
conditions, including measles, hepatitis, syphilis, and acquired immunodeficiency syndrome
(AIDS) , more detailed information on risk factors and other information needed for disease-
control programs is also collected by a state and local health departments and, in some instances,
is sent to CDC.

Surveillance for zoonotic diseases also involves monitoring animal hosts that either transmit the
disease directly to humans or are also susceptible to the disease. For various types of
encephalitis, for instance, detection of elevated virus titers in mosquitoes, wild birds, sentinel
flocks of chickens, or horses can signal that an outbreak of human disease may occur so that
mosquito-control activities can be initiated. Although most cases of notifiable conditions are
reported by clinicians, the role laboratories play in reporting notifiable conditions is becoming
increasingly important.

Strength and limitations of Notifiable Reportable Disease

Although many diseases or conditions are considered notifiable, compliance is poor in

most countries and sanctions are rarely enforced. As Sherman and Langitiuir noted in
1952, 'Our system of notification of individual case reports is a haphazard complex of
interdependence, cooperation, and goodwill among physicians, nurses, and county and state
health officers, school teachers, sanitarians, laboratory technicians, secretaries, and clerks.

Reporting is generally more complete for conditions such as plague and rabies that cause severe
clinical illness with serious consequences. Among the many factors that contribute to incomplete
reporting of notifiable conditions are lack of medical consultation for mild illnesses; concealment
by patients or health-care providers of conditions that might cause social stigma; lack of
awareness of reporting requirements; lack of interest by the medical community; incomplete
etiologic definition of notifiable conditions; inadequate case definitions for surveillance
purposes; variation in clinical expertise in diagnosing conditions in different areas; changes in
procedures for verifying reports from providers; variation in the use of laboratory confirmation; ;
variation in laboratory procedures; the effectiveness of control measures in effect; and priorities
of health officials at local, state, and national levels variation in laboratory procedures; the
effectiveness of control measures in effect; and priorities of health officials at local, state, and
national levels.

The extent of under-reporting can vary by risk group. Changes in case definitions and the extent
to which laboratory confirmation is required for reporting can also affect reporting for notifiable
conditions. surveillance case definitions have been developed for many communicable
diseases around the world. The degree to which standardized case definitions for notifiable-
disease reporting have been adopted varies, but recent experience suggests that there will be
The extent to which clinical reports are confirmed with laboratory findings can have a
substantial impact on reporting rates.

Despite their limitations, surveillance systems based on reporting of notifiable conditions are a
mainstay of public health surveillance. Unlike most other sources of routinely collected data,
information from notifiable-disease systems is available quickly and from all jurisdictions.
Knowledge of the specific characteristics of reporting for a particular condition is helpful in
interpreting the findings. While long-term trends may be difficult to interpret without
supplemental information, notifiable-disease systems can often detect outbreaks or other rapid
changes in disease incidence in a timely manner so that control activities can be initiated.
Notifiable-disease systems can also detect changes in patterns of disease by demographic
characteristics or risk groups.

Advances Beyond Communicable Disease

In recent years WHO has led the way in expansion of the concept of surveillance from its roots
in infectious disease to chronic diseases, injury, environmental health, occupational health,
substance use/misuse and social determinants of health e.g. poverty. The introduction of
computers and information technology has revolutionized the practice of public health
surveillance. It has vastly expanded the possibility of:
a. Decentralized, timely data collection, collation, and analysis
b. Rapid dissemination of surveillance information
c. Global linkage of participants through surveillance network

NCD and conditions are the leading cause of death and disability globally. The spectrum of
NCDs is wide, including heart disease, diabetes, arthritis, cancer, depression, asthma ,etc. They
have in common a long latent period and dare non communicable but may have communicable
origin (e.g. Hepatitis B). NCD surveillance includes all aspects of NCDs including their
determinants, events, healthcare utilization and outcomes.
Infectious diseases were broadly included in public health’s earliest surveillance efforts because
of the importance of preventing transmission. Additional communicable agents, of importance or
emerging importance were added to the system upon sufficient awareness.

Communicable Disease surveillance vs NCD surveillance

There are significant differences between communicable and non-communicable diseases that
affect haw each are surveilled. Health surveillance system are designed to address the factors
related to the different tyeps of diseases.

issue Non communicable Diseases Communicable Diseases

Temporality Latent casuality: exposure to More immediate
causaul factors occurs causaulity:exposure to the
decades before the onset of infectious agent often occur
the diseases days or hours before disease
onset
Disease course Usually protracted: response Can be short: response to
to treatment can treatment tends to be rapid
lag,exacerbations and and a cure is often likely
remissions of tha disease can
occur
Cause of Disease Multifactorial: a complex Identified infectious agent
interaction of riskfactors, ( there may be other
determinants and infectious contributing factors)
triggers
Public health intervention Often at the population level. At the individual population
The focus tends to be level. The focus is on case-
population base. based reporting with follow-
Interventions( eg Screening) up as well as population
rather that individual based interventions.
treatment interventions
Data sources It is practical to exploit Notifiable communicable
existing data bases that are diseases may include the
not usually designed for individual reporting of cases (
surveillance which may include
identifiers) and clinical
details in surveillance
databases
Data collection Tends to event oriented at Often person oriented(eg 25
present(for example, the yrs old female with hepatitis
number of hospitalization for B. reported to health unit)
acute myocardial infarction in
the past year at institution X)
there are also registries of
patients diagnosed with a
disease (eg cancer registry)
For NCDs latency is important; the impact of causal factors (including behaviours) accumulates
over time, often beginning decades before clinical diseases becomes apparent. NCDs have
protracted course, with both asymptomatic and symptomatic phases. Responses and outcomes
related to preventive interventions and treatments are subject to long lag times, lengthening the
surveillance cycle.

The causes of NCDs of multifactorial

a. Behavioral, occupational, and environmental risk factors
b. Genetic predisposition
c. Socio economic determinants and
d. Infectious triggers
In terms of public health control measures, one focus for NCDs is primary prevention that may
not result in immediate disease control and eradication. Conducting surveillance on major risk
determinants that can be modified-for example exercise, smoking, poverty, inequality-gives
public health information to inform sound and effective control and prevention of major NCDs in
the population.

Another focus is the continued assessment of

a. Mobility and mortality of health service planning
b. Screening for secondary prevention
c. Evaluation of interventions (both clinical and policy)

NDC diseases are driven by forces that include rapid unplanned urbanization, globalization of
unhealthy lifestyles and population ageing. Unhealthy diets and a lack of physical activity may
show up in people as raised blood pressure, increased blood glucose, elevated blood lipids and
obesity. These are called metabolic risk factors and can lead to cardiovascular disease, the
leading NCD in terms of premature death.

Metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs:

 raised blood pressure;

 overweight/obesity;
 hyperglycemia (high blood glucose levels); and
 hyperlipidemia (high levels of fat in the blood)

A public health Approach

Frequently, the time-consuming problems of collecting, managing, and storing

Surveillance-----Risk factor identification---intervention evaluation------implementation

Surveillance: what is the problem (problem)

Risk factor identification: what is the cause

Intervention evaluation: What works

Implementation: How do you do it (Response)

Cholera, a fatal intestinal disease, was rampant during the early 1800s in London, causing death
to tens of thousands of people in the area. Cholera was commonly thought to be caused by bad
air from rotting organic matter. John Snow is best known for his work tracing the source of the
cholera outbreak and is considered the father of modern epidemiology. He used the above public
health approach.

Definition of Public health surveillance

For public health professionals, surveillance is “the eyes and ears of public health”
The French word “surveillance” was introduced into the English language during the time of the
Napoleonic wars. It meant “to watch over an individual or group of individuals in order to detect
any subversive tendencies.” The scope of health-related events involved in public health
surveillance is ever expanding to meet the emerging and re-emerging public health challenges of
the day. Because there remains the potential of harm to individuals or communities through well-
intentioned health surveillance activities, we include a discussion of the legal and ethical aspects
of surveillance. We must always guard against the potential for abuse in surveillance activities.
.
Definition of Surveillance

 The continuous, systematic collection, analysis and interpretation of health-related data

needed for the planning, implementation, and evaluation of public health practice
 Systematic and continuous collection, analysis, and interpretation of data, closely integrated
with the timely and coherent dissemination of the results and assessment to those who have
the right to know so that action can be taken

The last six words of the Porta definition — “so that action can be taken" — must be kept in
mind during study. Without a link to public health practice and action, surveillance is simply a
data and information exercise which uses resources to no benefit.
Historically, the focus of public health surveillance was on mortality and infectious diseases.
Over the last century, as public health activities have broadened from an emphasis on sanitation
to include all aspects of health and the social determinants of health, so too have surveillance
activities. Health surveillance has evolved to inform and direct public health action both over the
short term, for example, in an infectious disease outbreak situation, and over the longer term in
relation to the prevention and control of infectious and chronic disease, congenital anomalies,
injury, and other health-related events.
Population health assessment focuses on the health of entire populations, rather than of
individuals. A population health approach focuses on improving the health of everyone,
regardless of social, economic, and/or environmental conditions, often using strategies such as
public health surveillance techniques.
Health Events Under Surveillance
Health surveillance systems vary from country to country as the availability of data and the
ability to link to clinical public health practice is changing worldwide.
To adequately appreciate current developments in public health surveillance it is necessary to:

1. Understand the basic principles of public health surveillance, including the typical
application of the cycle of surveillance.
2. Review the major objectives and uses of public health surveillance.
3. Understand the different types of surveillance.

Today, we have surveillance programs for the full spectrum of diseases, injuries, and risk factors.
However, for the purposes of these modules, we will concentrate on the major categories of
health events under surveillance today. These include:

1. Communicable diseases
2. Chronic diseases
3. Injuries
4. Behavioural risk factors & substance use
5. Environmental conditions that affect health

Understanding Public health Surveillance

Public health surveillance is the ongoing, systematic use of health data to guide public health
action in a timely fashion, and it is a core function of public health. Surveillance systems must be
closely linked to those responsible for public health activities and programmes, to enable
evidence-based public health decision-making and action.

A. Surveillance vs. Research

Surveillance is descriptive in nature, reporting the occurrence of injury or disease and its
determinants in a population. It primarily answers the questions

 what happened
 to what extent
 to whom
 when, and
 where?

Surveillance data must be cost-effective, and so are usually limited in detail (only the
information that is essential for the purpose), and relatively inexpensive to collect (lower costs
per person relative to intensive clinical investigations or research). Surveillance data are often
useful to suggest hypotheses for more detailed inquiry.
Research primarily tests or develops hypotheses by comparing and contrasting individual and
group experience. It uses various methods, both qualitative and quantitative, from case studies
and observational studies to experimental studies, such as the randomized controlled trial.
Research can also be conducted to look at the effectiveness of interventions and logistics of the
interventions.
Public health surveillance may share methodological strategies with epidemiological research but
how methods are applied vary. Reliability and validity of measurements are important for both
research and surveillance. However, research studies may collect data of breadth, depth or cost
that could not be maintained in an ongoing basis. In public health surveillance, the subject of
concern is the community or population. Often the people included in research are selected in a
way that allows one to address very specific research questions, and research samples often do
not represent real human populations or communities.
Surveillance, as well the methods and approaches used in surveillance are also in themselves
topics of research (“methodological research”). Applied surveillance methods require the
application of research findings and highly skilled specialists to employ these methods. Experts
in surveillance may have training in epidemiology, statistics, demography, survey methods,
measurement, and data .

B. Surveillance vs. Monitoring

These two terms are often mistakenly used interchangeably. Monitoring is typically the
intermittent performance and analysis of routine measurements, aimed at detecting changes in
the environment such as rainfall level or health status of a population. Monitoring typically
measures environmental attributes, which might involve counting people.
Surveillance is based on counting individual attributes and describing these at a population level.
Both activities may be continuous or episodic. The ability to identify any changes over time is
essential to surveillance, while monitoring may be directed more to detection of divergence from
some accepted norm.
It is of interest to note that environmental monitoring (of air quality, for example) may also be
used to guide public health action (recommendations for protecting vulnerable persons when air
quality is bad).
C. Surveillance and Health Information Systems
Public health surveillance systems are components of health information systems. Country-
specific health information systems include a range of population-based and health facility-based
data sources. The main population-based sources of health information are the census, household
surveys, and civil registration and vital statistics systems (i.e., births and deaths). These are high-
resource systematic data collection systems for the entire population and are vitally important for
the operation of modern democratic states. However, some of these sources are updated
infrequently — most countries conduct a census only once every five or ten years — so it can be
a challenge to have up-to-date information.
Other forms of health data include health system monitoring data (e.g. human resources, health
infrastructure, financing) and national health accounts, which provide a comprehensive picture of
health financing
D. Surveillance and Health Equity
Health equity means that all people can reach their full health potential without disadvantage due
to social position or other socially determined circumstance, such as ability, age, culture,
ethnicity, family status, gender, language, race, religion, sex, social class, or socioeconomic
status (NCCDH, 2013). Surveillance has been identified as a promising practice for addressing
health inequities.

Key Terms in Relation to Surveillance

Clinical care: prevention, treatment, and management of illness and the preservation of mental
and physical well-being through the services offered by medical and allied health professions;
also known as health care.

Determinant: factor that contributes to the generation of a trait.

Epidemic or outbreak: occurrence in a community or region of cases of an illness, specific

health-related behavior, or other health-related event clearly in excess of normal expectancy.
Both terms are used interchangeably; however, epidemic usually refers to a larger geographic
distribution of illness or health-related events.

Health outcome: result of a medical condition that directly affects the length or quality of a
person’s life.

Burden of Disease: Impact of a health outcome or disease on a population.

Case Definition: Set of criteria for determining if a person has a particular disease or other
health condition.

Chain of Infection: Links of infection from person to person.

Chart Abstraction: Recording information from patients’ medical records, including

demographic data (age, race/ethnicity, sex), as well as symptoms, treatments, and health
outcomes.

Community Transmission: Spread of disease from person to person in a community

Contact: Someone was physically close to a person who was potentially infectious with a
pathogen.

Contact Tracing: A strategy for slowing the spread of disease in which public health workers
communicate with infectious people to identify their contacts. They then follow up with those
contacts to provide guidance on how to quarantine themselves and what to do if they develop
symptoms of disease.

Data Visualization: Display of information in pictures, charts, and graphics to make the data
easier to understand and use.

Epidemiologic (Epi) Curve: Graphic representation of what has happened with a disease such
as changes in the number of cases, hospitalizations, or deaths over time.

Epidemiological (Epi) Link: Characteristic that links two cases, such as close contact between
two people or a common exposure.

Epidemiological Model: Mathematical representation that predicts where, how long, and how
far a disease will spread.

Exposure: Contact with a something that causes illness. In the case of an infectious disease, this
represents interaction with a human, animal, or environment from which the pathogen can be
transmitted.
Incidence: Number of people in a population who develop a disease or other health outcome
over a period of time.

Infectious Disease: Something that causes an infection that can lead to a disease.

Line List: Table containing a list of people with a specific disease or exposures.

Nationally Notifiable Disease: Disease that healthcare providers must report to state or local
health departments.

National Notifiable Diseases Surveillance System (NNDSS): Multifaceted program used by

around 3,000 public health departments that includes a surveillance system that monitors over
100 diseases.

Public Health Surveillance: Systematic collection, analysis, and interpretation of health data.

Prevalence: Number of people in a population who have a disease or other health outcome at
one point in time.

Hospitalizations: number of cases resulting in hospitalization.

Deaths: number of cases resulting in death.

Timeliness: to implement effective control measures.

Representation: to provide an accurate picture of the temporal trend of the disease.

Sensitivity: to allow identification of individual persons with disease to facilitate treatment,

Quarantine, or other appropriate control measures.

Specificity: to exclude persons not having disease.

PURPOSES of Public Health Surveillance

Public health surveillance data are used to assess public health status, define public health
priorities, evaluate programs, and conduct research. Surveillance data tell the health officer
where the problems are, whom they affect, and where programmatic and prevention activities
should be directed. Such data can also be used to help define public health priorities in a
quantitative manner and in evaluations of the effectiveness of programmatic activities. Results of
analysis of public health surveillance data also enable researchers to identify areas of interest for
further investigation
.
The analysis of surveillance data is, in principle, quite simple. Data are examined by measures of
time, place, and person. The routine collection of information about reported cases of congenital
syphilis in the United States, for example, reflects not only numbers of cases (Figure 1.1),
geographic distribution, and populations affected, but also indicates the effects of crack cocaine
use and changing sexual practices over the past 10 years. The examination of routinely collected
data show where rates of salmonellosis by county in New Hampshire and in three contiguous
states. Mapping these data illustrates the pattern of the spread of disease across state boundaries
(Figure 1.2). The examination of death certificates for data on homicide identifies high-risk
groups and shows that the problem has reached epidemic proportions among young adult men
(Figure 1.3).

USES

Portray natural history Of Disease

The uses of surveillance are shown in Table 1.1. Portrayal of the natural history of disease can be
illustrated by the surveillance of malaria rates in the United States since 1930 (Figure 1.4). In the
1940s, malaria was still an endemic health problem in the southeastern United States to the
degree that persons with febrile illness were often treated for malaria until further tests were
available. After the Malaria Control in the War Areas Program led to the virtual elimination of
endemic malaria from the United States, rates of malaria decreased until the early 1950s, when
military personnel involved in the conflict in Korea returned to the United States with malaria.
The general downward trend in reported cases of malaria continued into the 1960s until, once
again, numbers of cases of malaria rose, this time among veterans returning from the war in
Vietnam. Since that time, we have continued to see increases in numbers of reported cases of
malaria involving immigrant populations, as well as among U.S. citizens traveling abroad.

Detection of Epidemics

Surveillance data can be used also to detect epidemics. For example, during the swine influenza
immunization program in 1976, a surveillance system was established to detect adverse sequelae
related to the program. Working with state and local health departments, CDC was able to detect
an epidemic of Guillain-Barr6 syndrome, which rapidly led to the termination of a program in
which 40,000,000 U.S. citizens had been vaccinated. However, most epidemics are not detected
by such analysis of routinely collected data but are identified through the astuteness and alertness
of clinicians and public health officials of the community. From a pragmatic point of view, the
key point is that when someone does note an unusual occurrence in the health picture of a
community, the existence of organized surveillance efforts in the health department provides the
infrastructure for conveying information to facilitate a timely and appropriate response.

Documentation of the Distribution and Spread of Disease

The distribution and spread of disease can be documented from surveillance data, as seen in the
county-specific data on salmonellosis (Figure 1.2). U.S. cancer mortality statistics have also been
mapped at the county level to identify a variety of geographic patterns that suggest hypotheses
on etiology and risk. Recognition of such clusters can lead to further epidemiologic or laboratory
research, sometimes using individuals identified in surveillance as subjects in epidemiologic
studies. The association between the periconceptual use of multivitamins by women and the
development of neural tube defects by their children was documented using children identified in
a surveillance system for congenital malformations.

Testing of Hypothesis
Surveillance data can also be used to test hypotheses. For example, in 1978 the U.S. Public
Health Service announced a measles elimination program that included an active effort to
vaccinate school-age children. Because of this program and the state laws that excluded from
school students who had not been vaccinated, CDC anticipated a change in the age pattern of
persons reported to have measles. Before the initiation of the program, the highest reported rates
of measles were for children 10-14 years of age. As predicted, almost immediately after the
school exclusion policy was implemented, there was not only a general decrease in the number
of cases but also a shift in peak occurrence from school-age to preschool-age children (Figure
1.5). By 1979, there were even lower levels of measles incidence and altered age-specific
patterns.

Control and Prevention measures

Surveillance data can be applied in evaluating control and prevention measures. With routinely
collected data, one can examine --without special studies--the effect of a health policy. For
example, the introduction of inactivated poliovirus vaccine in the United States in the 1950s was
followed by a dramatic decrease in the number of reported number of cases of paralytic
poliomyelitis, and the subsequent introduction in the 1960s of oral poliovirus vaccine was
followed by an even greater decline (Figure 1.6)

Changes in Infectious agent Monitoring

.
Efforts to monitor changes in infectious agents have been facilitated using surveillance data. In
the late 1970s, antibiotic-resistant gonorrhea was introduced into the United States from Asia.
Laboratory- and clinical -practice-based surveillance for cases of gonorrhea enabled public
health officials to monitor the rapid diffusion of various strains of this bacterium nationally and
facilitated prevention activities, including notifying clinicians of proper treatment procedures
(Figure 1.7). Similarly, the National Nosocomial Infections Surveillance System, a voluntary,
hospital -based surveillance system of hospital-acquired infections, has been used to monitor
changes in antibiotic-resistance patterns of infectious agents associated with hospitalized
patients.

As noted earlier, the first use of surveillance was to monitor persons with a view of imposing
quarantine as necessary. Although this use of surveillance is rare in modern-day United States, in
1975—with the introduction of a suspected case of Lassa fever—over 500 potential contacts of
the patient were monitored daily for 2 weeks to assure that secondary spread of this serious
infectious agent did not occur

Detecting Changes in Health Practice

.
Surveillance data can also be used to good effect for detecting changes in health practice. The
increasing use of various technologies in health care has come to be an issue of growing concern
over the past decade; surveillance data can provide useful information in this area . For example,
in the United States since 1965, the rate of cesarean delivery has increased from approximately
<5% to nearly 25% of all deliveries (Figure 1.8). Data such as these are useful both in planning
research to learn the causes of these changes and in monitoring the impact of such changes in
practice and procedure on outcomes and costs associated with health care.

Planning

Finally, surveillance data are useful for planning. With knowledge about changes in
the population structure or conditions that might affect a population, officials can, with more
confidence, plan for optimizing available resources. For example, data on refugees entering the
United States from Southeast Asia in the early 1980s were broadly applicable; they told where
people settled, described the age and gender structure of the population, and identified health
problems that might be expected in that population. With this information, health officials were
able to plan more effectively the appropriate health services and preventive activities for this new
population.

Components of Public health surveillance

Disease surveillance concurrently involves the health care delivery system, the public health
laboratory, and epidemiologists. Each of these sectors contributes to the four basic components
of surveillance, which are (1) collection, (2) analysis, (3) dissemination, and (4) response.
Collection and analysis can be conducted at the local, state, or international level by public
agencies as well as by private industry. Dissemination and response are specific public health
activities. Thus, disease surveillance is the ongoing, systematic collection and analysis,
interpretation, and feedback of outcome-specific data. As such, surveillance may monitor cases
of disease reported by clinicians or identified in laboratories, or it may monitor changes in
practice or other behaviors of public health importance.

Types of Public Health Surveillance

Passive Surveillance: A system whereby a health institution receives routine reports submitted
from health facilities, such as hospitals, clinics and public health units, the community, or other
sources. There is no active search for cases. This is the most common form of surveillance,
which includes the surveillance of diseases and other public health events using routine
surveillance, routine health management and information system or any other public health
information system.
Active Surveillance: It involves an ongoing search for cases in the community or health
facilities. This may involve regular contacts with key reporting sources, by making telephone
calls to health care workers (HCWs) at a facility or laboratory or physically moving to the source
and carrying out record review of data. Examples include active search for cases of measles and
polio, including during outbreaks, where mechanisms must be put in place for active finding of
additional cases.
Integrated disease surveillance: It is an approach that aims at collecting health data for multiple
diseases, using standardized tools. To ensure robust early warning and prompt response, the
IDSR data collection and analysis system relies on two main channels of information or signal
generation: Indicator-based surveillance (IBS); and event-based surveillance (EBS).
Indicator-Based surveillance: IBS is the systematic (regular) identification, collection,
monitoring, analysis and interpretation of structured data, such as indicators produced by well-
identified, mostly health-based formal sources.

Common methods of indicator-bases Surveillance

a) facility-based surveillance: All reporting units, such as health facilities, are required to report
on a weekly, monthly, quarterly, or annual basis to the next level, based on the categories of the
diseases, conditions and events. Additionally, they are also required to report any epidemic-
prone disease to the next level immediately.
b) Case-Based Surveillance: This Involves the ongoing and rapid identification of identifiable
cases for the purpose of case follow-up. It is the type of surveillance used for diseases targeted
for elimination or eradication or during confirmed outbreaks. In these scenarios, every individual
case identified is reported immediately to the next level, using a case-based form.
c) Sentinel surveillance: This type of surveillance is done for specific conditions in a specific
cohort, such as a geographical area or population subgroup, to estimate trends in a larger
population. A given number of health facilities or reporting sites are usually designated as
sentinel sites for monitoring the rate of occurrence of priority events such as pandemic or
epidemic events and other health events of public health importance, where they act as early
warning and reporting sites. Sentinel sites are usually designated because they are representative
of an area or are in an area of likely risk for a disease or condition of concern. Examples of
sentinel surveillance include sentinel surveillance for influenza rotavirus, pediatric bacterial
meningitis, and environmental sewage sampling for polio.

d) Syndromic surveillance: This is an active or passive system that uses Standard Case
Definitions (SCD), based entirely on clinical features, without any laboratory diagnosis.
Examples of these are: collecting the number of cases of Acute Flaccid Paralysis (AFP) as an
alert for polio; acute watery diarrhea (AWD) among people aged two years and older as an alert
for cholera; “rash illness” as an alert for measles; acute hemorrhagic fever as an alert for viral
hemorrhagic diseases, or severe acute respiratory infection or influenza-like illness as alerts for
influenza. Because of the lack of specificity of this system, reports require more investigation
from higher levels.
e) Laboratory-based surveillance. This consists of surveillance conducted at laboratories to detect
events or trends, which may not be a problem at other locations or originate from laboratory
testing, mainly done routinely or used when conducting sentinel surveillance. Laboratories can
be the source of an initial alert for a specific outbreak or public health event that necessitates
further epidemiological investigations. For example, the laboratory may be the first to detect the
emergence of resistant strains, such as multi-drug resistant tuberculosis (MDR-TB), in the
community. Other examples of laboratory-based surveillance are virologic surveillance for
influenza and bacteriological surveillance under the antimicrobial resistance (AMR) surveillance
system. Recently, WHO established a global antimicrobial resistance surveillance system
(GLASS) for clinical specimens, which is focusing initially on priority human bacterial
infections namely E. coli, K. pneumonia, S. aureus, S. pneumoniae, Salmonella spp., Shigella
spp and N. gonorrhea. This type of laboratory surveillance provides information about AMR
incidence, prevalence, and trends.
f) Disease-specific surveillance. involves surveillance activities aimed at targeted health data for
a specific disease for vertical surveillance. Examples include tuberculosis, malaria, and HIV
surveillance systems.
g) Community-based surveillance (CBS). is defined as the systematic detection and reporting of
events of public health significance within the community-by-community members. CBS
incorporates both IBS and EBS methods. Under CBS, focal persons are identified to report cases
or events to the designated focal point at nearby local health delivery points. CBS strategies
focus on two approaches to collect community information. The first one relies on identifying
and reporting events based on agreed indicators (lay case definitions). For example, trusted
community members are trained to identify diseases such as measles, cholera, polio and Guinea
worm, using community (lay) case definition and use the standardized reporting system to the
next level.

ATTRIBUTES OF THE SYSTEM

Each surveillance system has characteristics or attributes that contribute directly to its ability to
meet its specific objectives. The combination of these attributes determines the strengths and
weaknesses of the system. The attributes must be balanced against each other, (e.g., high
sensitivity may only be possible with a complex reporting system from a wide array of
providers)

QUALITATIVE ATTRIBUTES:

Simplicity and Flexibility

In describing a surveillance system, three desirable qualitative attributes should be
addressed: simplicity, flexibility, and acceptability. Simplicity of a surveillance system refers
both to its structure and to its ease of operation. Surveillance systems should be as simple as
possible, while still meeting their objectives. It may be useful to think of the simplicity of a
surveillance
system from two perspectives: the design of the system and the size of the system.

The following measures might be considered in evaluating the simplicity of a system:

a. Amount and type of information necessary to establish a diagnosis.
b. Number and type of reporting sources,
c. Method(s) of transmitting case information/data,
d. Staff training requirements.
e. Type and extent of data analysis,
f. Amount of computerization,
g. Methods of distributing reports, and
h. Amount of time spent operating the system.
The cost estimates for a system are also an indirect indicator of simplicity. Simple systems
usually cost less that complex ones. Another consideration is the ability of the system to adapt to
changing needs such as the addition of new conditions or data collection elements. This
characteristic is termed "flexibility."

Acceptability

Acceptability reflects the willingness of individuals and organizations to participate in the

surveillance system. This attribute refers to the acceptability of the system to health department
staff and at least equally importantly to persons outside the sponsoring agency, (e.g., doctors or
laboratory staff) who are asked to report cases of certain kinds of health problems. To assess
acceptability, one must consider the points of interaction between the system and its participants,
including subjects (persons identified as having cases) and reporters. Indicators of acceptability
include the following: a) subject or agency participation rates; b) interview completion rates and
question refusal rates if the system involves case interviews. c) completeness of report forms; d)
physician, laboratory, or hospital/facility reporting rates; and e) timeliness of reporting.

QUANTITATIVE ATTRIBUTES
The four quantitative attributes of a surveillance system include sensitivity, predictive value
positive, representativeness, and timeliness. These are often difficult to measure precisely, but
even indirect estimates can be useful in helping to improve the efficiency of a system and in
comparing it with other systems.

Sensitivity
The sensitivity of a surveillance system can be considered on two levels. First, the completeness
of case reporting - - i .e. , the proportion of cases of a disease or health condition that are
detected by the surveillance system
.
The sensitivity of a surveillance system is affected by the likelihood that
• persons with certain health conditions seek medical care.
• the condition is correctly diagnosed which reflects the skill of care
providers and the accuracy of diagnostic tests; and
• the case is reported to the system once it has been diagnosed.

These factors also apply to surveillance systems that do not fit the traditional disease/care-
provider model. For example, the sensitivity of a telephone-based
surveillance system of morbidity or risk factors would be affected by
• the number of people who have telephones, who are at home when the
surveyor calls, and who agree to participate.
• the ability of persons to understand and correctly answer the questions.
and
• the willingness of respondents to report their status.
Elements of public health surveillance

The basic elements of public health surveillance are, Timeliness ; to implement effective control
measure, Representation; to provide an actual picture of the trend of disease; Sensitivity; to allow
identification of individual person with disease to facilitate treatment, quarantine or other
appropriate control measure, and specificity; to exclude person not having the disease.

Cycle of Public Health Surveillance

Public health surveillance is composed of an ongoing cycle of activities that involve health
workers, public health agencies, and the public.
Surveillance information must be information for action and linked to those who can take
action to prevent or control further harm to individuals or communities. Depending on the
circumstance, this group may extend beyond health to include employers, vaccine manufacturers,
and other non-health related government agencies.
Once a surveillance system is established, the cycle begins when cases of a disease or some other
health event occur and are reported by a health worker to public health agencies. The cycle
continues as information about these cases is collated, analyzed, and disseminated to those who
need to know, which may include the health worker who first reported the event, health agencies,
and the public. Finally, information gathered may be used to support evaluation of the whole
system with the aim to have better information to guide more effective practice.
The cycle includes the following components:

1. Collection of data
2. Integration or collation of data
3. Analysis and interpretation of data
4. Creation of surveillance products Diagram
5. Dissemination of products
6. Action
7. Evaluation

Collection of Data: Data are the smallest units of description with no context provided. They
may be presented as words number or symbols. Health data is any data “related to health
conditions, reproductive outcomes, causes of death, and quality of life” for an individual or
population. Data collected in surveillance systems typically include demographic, socioeconomic
and clinical characteristics of the population under surveillance, data on key outcomes such as
disease complications and mortality, and data on potentially mitigating or aggravating behaviors
or co-morbid conditions referred to as risk factors.
Data can be collected from a variety of sources. For example, health data can be collected as part
of surveys that can be population-based (i.e., designed to collect data from populations that are
regionally or nationally representative) or they may be healthcare provider-based (i.e., designed
to collect data from populations receiving health care services). For example, sentinel
surveillance systems have been established in health care sites such as hospitals, clinics, or care
 providers’ offices to monitor key health events such as cases of influenza or cancer. The main
purpose of such provider-based surveillance systems is to obtain timely information on changes
in the occurrence of a disease or condition that can inform preventive public health activities.
Data can also be collected for a wide variety of purposes using a registry. There are different
types of registries including patient organization, medical and health ministry registries.
Integration or collation of data: Health data integration is considered a key component and, in
some cases, a pre-requisite in nearly every systematic attempt to achieve integrated care. In the
context of health care, data integration is a complex process of combining multiple types of data
from different sources into a single infrastructure, allowing multiple levels of users to access,
edit, and contribute to an electronic record of health services (EHRs). The types of data
integration that are performed depend on the quality, quantity, and capability of the service
performing the integration as well as the needs of the current and future users.
Analysis and interpretation of Data: Analysis and interpretation of surveillance data are the
processes of examining the collected data to understand the distribution and occurrence of
diseases or health events in populations. Analysis involves applying statistical methods to
describe and compare the data, such as calculating rates, proportions means, medians, etc.
Interpretation involves identifying trends, patterns ,outliers, and anomalities in the data, and
explaining their possible causes and implications for public health actions.
Some steps for analysis and interpretation of surveillance data are

 Define the objective and scope of the analysis

 Clean and validate the data
 Summarize and display the data using tables, graphs, charts, maps, etc.

Ongoing analysis of surveillance data is important for detecting outbreaks and unexpected
increases or decreases in disease occurrence, monitoring disease trends, and evaluating the
effectiveness of disease control programs and policies. Analysis of surveillance data begins with
characterizing the pattern of disease reports by person, place, and time. Patterns of disease
reports should be compared at different times (e.g., the number of mumps cases reported in 2005
compared with the number of cases in 2006); in different places (e.g., the number of pertussis
cases reported in one district compared with the number in another district); and among different
populations (e.g., the number of measles cases reported among infants, preschool age children,
school age children, adolescents, and adults).
Data should be analyzed and presented in a compelling manner so that decision makers at
all levels can readily see and understand the implications of the information. Knowledge of the
characteristics of the audiences for the information and how they might use it may dictate any of
a variety of communications systems. Routine, public access to the data—consistent with privacy
constraints- -should be planned for and provided.

Creation of Surveillance products: Creation of surveillance products refers to the process of

transforming the collected and analyzed data into useful information that can be communicated
to the stakeholders and the public. Surveillance products can include reports, bulletins, alerts.
Dashboards, maps, charts, etc.
 Some examples of surveillance products are:

 The WHO Coronavirus (COVID-19) Dashboard that provides updated information on the global
situation of the pandemic.
 The CDC Flu View that tracks influenza activity in the United States and provides weekly
summaries and interactive maps.
 The Global Polio Eradication Initiative that publishes regular updates on polio cases and
outbreaks around the world.

Dissemination of products: Dissemination of products in public health surveillance refers to the

process of sharing the surveillance products (such as reports, bulletins, alerts, dashboards, etc.)
with the relevant audiences (such as health-care providers, public health agencies, policy makers,
media, and the general public) . The purpose of dissemination is to inform and educate the
audiences about the status and trends of diseases or health events, and to provide evidence-based
recommendations for prevention and control
Some factors to consider for effective dissemination are:

 The content, format, and frequency of the products

 The communication channels and platforms (such as email, website, social media, etc.)
 The feedback mechanisms and evaluation methods
 The ethical and legal issues (such as confidentiality, consent, etc.)

Action: Action in public health surveillance refers to the process of using the surveillance data
and products to guide public health interventions and policies that aim to prevent and control
diseases or health events 12.
Action can be divided into two types:

 Acute (epidemic-type) response: This involves rapid detection and investigation of outbreaks or
emerging threats and implementing immediate measures to contain or mitigate them. Examples
of acute response are contact tracing, isolation, quarantine, vaccination, etc.
 Planned (management-type) response: This involves long-term planning and evaluation of
programs or strategies that address the underlying causes or risk factors of diseases or health
events. Examples of planned response are health promotion, disease prevention, health system
strengthening, policy development, etc.

Action is influenced by the public health interpretation of the surveillance data and products,
which considers the context, significance, and implications of the findings. Action also
influences the surveillance system by providing feedback and recommendations for
improvement.

Evaluation: Evaluation in public health surveillance refers to the process of assessing the
performance and usefulness of a surveillance system in meeting its stated purposes and
objectives 12.
Evaluation can help to identify the strengths and weaknesses of a surveillance system, and to
provide evidence-based information and recommendations for improvement or modification 13.
 Some steps for evaluation are:

 Engage stakeholders
 Describe the surveillance system
 Focus the evaluation design
 Gather credible evidence
 Justify conclusions
 Ensure use and share lessons learned

Some criteria for evaluation are:

 Simplicity
 Flexibility
 Data quality
 Acceptability
 Sensitivity
 Predictive value positive
 Representativeness
 Timeliness
 Stability