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May 2008
Public Health Surveillance

The Best Weapon to Avert Epidemics
Public health surveillance provides real-time, early warning control program might provide information only every one to
information to decisionmakers about health problems that five years, depending on the prevalence level, and could do so
need to be addressed in a particular population. It is a critical through household surveys, described below.
tool to prevent outbreaks of diseases and develop appropriate,
rapid responses when diseases begin to spread. Training and
equipping health workers in developing countries with the Types of Surveillance Strategies
skills and technology for surveillance are an absolute necessity The following are selected surveillance strategies, which
in today’s world. can each meet top managers’ needs for different types of
With millions of people traveling the globe every day, diseases information:
cross boundaries within days and even hours. Recent experiences Sentinel surveillance systems consist of a sample of health
have shown that epidemics are a threat to economies as well as facilities or laboratories in selected locations that report all
a public health menace. While the tools and expertise exist to cases of a certain condition to indicate trends in the entire
avert epidemics, political commitment and financial support population. Sample reporting is a good way to use limited
are needed to ensure that all countries have systems in place to resources to monitor suspected health problems. Examples
detect, analyze, and respond to diseases as soon as they emerge. include networks of health providers reporting cases of
influenza or a laboratory-based system reporting cases of
certain bacterial infections among children.
What Is Public Health Surveillance?
Household surveys can be used to monitor diseases if the
Public health surveillance is the ongoing, systematic collection,
surveys are consistent and repeated periodically, say every
analysis, and interpretation of data that is then disseminated
three to five years. The surveys are population-based; that is,
to those responsible for preventing diseases and other health
they select a random sample of households representative of
conditions. The data allow managers to respond quickly to a
the whole population. Examples include demographic and
population’s health needs. This information is also essential
health surveys in developing countries and the behavioral
for ministries of health, ministries of finance, and donors to
risk factor surveillance system in the United States.
monitor how well people are served. Surveillance enables
decisionmakers to lead and manage effectively. Laboratory-based surveillance is used to detect and monitor
infectious diseases. For example, for food-borne diseases such
Because the objective of surveillance is to guide health
as salmonella, the use of a central laboratory to identify specific
interventions, the nature of public health concerns drives the
strains of bacteria allows more rapid and complete identification
design and implementation of the system. For example, if the
of disease outbreaks than a system that relies on reporting of
objective is to prevent the spread of acute infectious diseases,
syndromes from clinics. In the United States, the Centers for
such as SARS (severe acute respiratory syndrome—see box
Disease Control and Prevention maintain PulseNet, an Internet-
on page 2), health program managers need to intervene
based network of laboratories that uses standard methods for
quickly. To do so, they need a system that provides early
identifying and reporting the genetic makeup of disease-causing
warning information from clinics and laboratories.
agents. PulseNet is also active in Canada and Europe and is
In contrast, chronic diseases and heath-related behaviors, expanding in Asia and the Pacific and Latin America.
such as smoking, change more slowly, and managers need
Integrated disease surveillance and response (IDSR) strategies
only to monitor changes once a year or even less often. A
bring together data from health facilities and laboratories
surveillance system to measure the effects of a tuberculosis

Fogarty International Center of the U.S. National Institutes of Health The World Bank World Health Organization Population Reference Bureau | Bill & Melinda Gates Foundation
 in systems designed to monitor communicable diseases.
The emphasis is on integrating surveillance with response.
IDSR has several core activities: detecting, registering, and
confirming individual cases of disease; reporting, analysis,
use, and feedback of data; and preparing for and responding
to epidemics. In Africa, the World Health Organization is
helping a number of countries to build the infrastructure and
skills to develop and use these integrated systems.
Examples of Uses of Surveillance
Preventing Major Outbreaks of Disease
The AIDS epidemic tragically spread to many countries in
Sub-Saharan Africa over many years before it was detected and
control measures were started in the late 1980s. In recent years,
surveillance and response systems have been more effective at
identifying early and thereby preventing the spread of infectious
diseases. Examples include the SARS epidemic in China (see
box), the Ebola virus in Uganda, and avian flu in Thailand.
In 2000 in northern Uganda, a public health student discovered
a hospital jammed with patients with high fevers, diarrhea, and
bleeding. He reported cases of viral hemorrhagic fever to the
Ministry of Health, which quickly arranged for samples to be
flown to South Africa (the nearest specialized laboratory) for
analysis. Once the laboratory tests confirmed that the illness
was Ebola, which usually kills more than half of those infected,
the health minister quickly mobilized a surveillance and control
team to set up services in the affected region. Because the
disease spreads rapidly and many people were fleeing the area,
the government mobilized the military to help identify cases;
invited international health experts to assist with treatment and
control; and set up surveillance nationwide. Within one year, the
epidemic was controlled, with a fatality rate lower than that of
previous Ebola outbreaks. Partially because of the lessons of this
epidemic, Uganda has become one of the leading countries in
implementing the IDSR program.
Thailand was host to one of the largest epidemics of avian
influenza (bird flu) identified in eight Asian countries in early
2004. Later that year, the disease spread from birds to humans,
killing 32 of the 44 people infected. Recognizing the global
threat posed by such a disease, the Thai Ministry of Health, in
partnership with field epidemiologists and WHO, supported
laboratory studies that showed that the disease was being spread
from human to human. The Thai example was critical in
raising public awareness of the possibility of a global catastrophe
2 | Public Health Surveillance: The Best Weapon to Avert Epidemics | Disease Control Priorities Project
caused by avian flu. It also showed that the disease can be
controlled with proven epidemiologic methods—including
rapid, on-site investigation by trained specialists—and good
communications.
Surveillance and the Global
Response to SARS
In November 2002, public health officials detected an epidemic
of severe pneumonia of unknown cause in Guangdong
province, China, and put in place control measures based on
the way the disease spread from person to person. In February
and March 2003, the disease spread to Hong Kong, Vietnam,
Singapore, Canada, and elsewhere. Health experts named it
severe acute respiratory syndrome (SARS); identified a specific
virus as the cause by March 2003; and mapped the full genome
by April. The pandemic ended in July 2003, as transmission
was interrupted after more than 8,000 patients in 26 countries
were affected and 774 deaths were confirmed.
The World Health Organization spearheaded the effort to
control the pandemic, working with national and subnational
health workers, the Chinese Center for Disease Control, and
a team of field epidemiologists. (Field epidemiologists are
“disease detectives” who work on-site to find and interview
patients with diseases, collect specimens, and apply statistical
methods to assess the causes of illness and recommend
control measures.) In Canada, which had the most cases
of SARS outside of China, field epidemiologists began
investigations, developed prevention and control guidelines,
informed the media and the public, and planned and
implemented studies of the disease.
The success of this global effort to control the first new
epidemic of the 21st century depended on open collaboration
among scientists and politicians of many countries, and
rapid communication of surveillance data among countries.
Once the spread of SARS was recognized, a worldwide
surveillance network was established based on an agreed-
upon case definition that was specific enough to ensure
accurate reporting.
Meeting Other Critical Health
Information Needs
Because health managers need information for a wide variety
of purposes, different types of surveillance systems have been
developed, including:
 • Monitoring the adverse effects of environmental
hazards such as toxic chemicals and biologic agents in
the air, water, soil, or food.
• Collecting data on injuries, which are among the
leading causes of death and disabilities worldwide,
most of which are preventable.
• Detecting and managing outbreaks of bioterrorism,
in which the causes are man-made but the outbreaks
are similar to other epidemics: Early detection and
warning are critical to saving lives.
• Monitoring and responding to disasters and complex
emergencies, including mapping of possible hazards
and training of rescue teams.
• Monitoring refugee populations to identify and
eliminate preventable causes of illness and death in
these communities.
Who Should Pay for Surveillance?
The spread of diseases is expensive and can be economically
devastating in affected countries, as HIV/AIDS in Africa has
demonstrated. Although the private sector benefits from
disease surveillance and response, surveillance systems are an
essential element of public health and therefore fall within the
responsibility of countries and international organizations.
Public health surveillance can be considered a global public good
when it is used to eradicate diseases that cross national borders.
The greatest need for and use of public health surveillance
is within countries; therefore, governments should and do
bear most of the financial and human resource costs of
building and maintaining surveillance systems. Nevertheless,
many developing countries will require assistance from
international donor and technical agencies for some time to
build the skills and infrastructure necessary to protect the
local population, as well as those of other countries, from
outbreaks of disease.
Improvements Needed in Developing
Countries
A challenge for developing countries is to ensure the quality
and effectiveness of surveillance and public health responses.
Accomplishing this will require developing and maintaining a
cadre of competent and motivated surveillance and response
workers. Core competencies that need to be developed include
field epidemiology (the on-site investigation and analysis of
diseases); and the ability to conduct scientific investigations,
analyze and interpret the findings, and recommend logical and
practical actions based on the findings.
Developing country governments, their funding partners, and
multilateral organizations need to invest in the infrastructure
and training to make surveillance systems work well. Using new
information technologies and compatible reporting systems
will help bring about the needed improvements. Increasingly,
new technologies such as software available over the Internet
and geographic information systems are transforming public
health surveillance in developing countries. The U.S. Centers
for Disease Control and Prevention, along with WHO, have
collaborated with more than 30 countries since 1975 to
strengthen health systems and train health workers in the latest
methods of disease detection and response.
Conclusions
To be useful, public health surveillance must be approached as a
scientific enterprise, applying rigorous methods to address critical
public health concerns. The problems facing the developing and
developed worlds are increasingly similar and overlapping.
The rise of global epidemics, in particular, calls for integrated,
worldwide networks that bring together health practitioners,
researchers, governments, and international organizations to
address surveillance needs that cross national boundaries.
Although it is reassuring that disease outbreaks such as SARS,
Ebola, and avian flu have thus far been averted through rapid
surveillance and response, there is no reason for complacency.
Health experts are certain there will be further outbreaks,
possibly of SARS or avian flu. Thus, the question is not
whether but when new disease outbreaks will occur, and
whether the world community will be ready for them.
For More Information
Peter Nsubuga, Mark E. White, Stephen B. Thacker, Mark A.
Anderson, Stephen B. Blount, Claire V. Broome, Tom M. Chiller,
Victoria Espitia, Rubina Imtiaz, Dan Sosin, Donna F. Stroup,
Robert V. Tauxe, Maya Vijayaraghavan, and Murray Trostle. 2006.
“Public Health Surveillance: A Tool for Targeting and Monitoring
Interventions.”In Disease Control Priorities in Developing Countries,
2nd ed., ed. D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne,
M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, 997-1015.
New York: Oxford University Press.
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