Introduction to Public Health

Surveillance

Goals

Define surveillance, explain surveillance

systems
Describe basic surveillance techniques
by person, place, time
Touch on importance of standardization
Provide overview of how to present
surveillance data

Surveillance

For persons who need to carry out

surveillance activities but have little
prior experience or training
Also helpful for people who would like
to better understand the process and
reasoning behind surveillance methods
and interpretation

What Is Surveillance?

Centers for Disease Control and

Prevention (CDC): epidemiologic
surveillance is ongoing systematic
collection, analysis, and interpretation
of health data essential to the planning,
implementation, and evaluation of
public health practice, closely integrated
with the timely dissemination of these
data to those who need to know.

Why Is Surveillance
Important?

Collecting data is merely one step

Critical goal is to control and/or prevent
diseases

Any data collected must be organized and

carefully examined
Any results need to be communicated to
public health and medical communities

Why Is Surveillance
Important?

Vital to communicate results

During potential outbreak so public health

and medical communities can help with
disease prevention and control efforts
During non-outbreak times to provide
information about baseline levels of
disease

Baseline provides information to public health

officials monitoring health at community level,
serves as reference in future outbreaks

Surveillance Systems

Classified as passive or active

Passive surveillance: local and state health
departments rely on health care providers or
laboratories to report cases of disease

Primary advantage is efficiency: simple and

requires relatively few resources
Disadvantage is possibility of incomplete data due
to underreporting
Majority of public health surveillance systems are
passive

Surveillance Systems

Active surveillance: health department

contacts health care providers or laboratories
requesting information about conditions or
diseases to identify possible cases

Requires more resources than passive surveillance

Useful when important to identify all cases

Example: between 2002 and 2005, active surveillance

used to detect adverse events associated with smallpox
vaccine. (2)

Why Is Surveillance
Important?

Surveillance information has many uses:

Monitoring disease trends

Describing natural history of diseases
Identifying epidemics or new syndromes
Monitoring changes in infectious agents
Identifying areas for research
Evaluating hypotheses
Planning public health policy
Evaluating public health policy/interventions

Why Is Surveillance
Important?

Examples of uses of surveillance data:

Evaluating impact of national vaccination

campaigns
Identifying AIDS when unknown syndrome
Estimating impact of AIDS on US health care
system in 1990s (using mathematical models
based on surveillance data)
Identifying outbreaks of rubella and congenital
rubella among Amish and Mennonite communities
in 6 states in 1990 and 1991 (3)
Monitoring obesity, physical activity,
other
indicators for chronic diseases

How to Conduct Surveillance

Surveillance data allow description and

comparison of patterns of disease by
person, place, and time
Several ways to describe and compare
patterns, from straightforward
presentations to statistically complex
analyses
Will concentrate on simple techniques

How to Conduct Surveillance:

Person

When available, demographic characteristics

such as gender, age, race/ethnicity,
occupation, education level, socio-economic
status, sexual orientation, immunization
status can reveal disease trends

Example: looking at Streptococcus pneumoniae, a

common cause of community-acquired pneumonia
and bacterial meningitis, examining distribution of
cases by race provides important information
about burden of disease in different populations

How to Conduct Surveillance:

Person Numbers and Rates

Table 1 shows data

collected on

Streptococcus
pneumoniae from CDC
Emerging Infections
Program Network, a
surveillance program
that collects data from
multiple counties in 10
US states (4)

How to Conduct Surveillance:

Person Numbers and Rates

Data show majority of

cases reported among
whites
Can draw only limited
conclusions because race
not recorded for 684 cases
(15%)
Shows only number of
reported cases, not rate
Total number of
individuals by race needed
to determine if there is a
disproportionate burden of
disease among races

How to Conduct Surveillance:

Person Numbers and Rates

Table 2 shows same

data with 2006
population
estimates of total
number of persons
in each racial
category used to
calculate disease
rates (4)

How to Conduct Surveillance:

Person Numbers and Rates

While Table 1 showed

that whites had the
highest number of cases,
Table 2 indicates that the
rate of disease was
highest among blacks
Using rates, stratifying
by race provides
information about
disease burden in
different populations
that would not be
apparent from total case
numbers

More on Rates

RatesA rate is an expression of the

frequency with which an event occurs in a
defined population
Using rates rather than raw numbers is
essential to compare different classes of
persons or populations at different times or
places. (5)

Rate = number of events in a specified period

average population during the period

How to Conduct Surveillance:

Place

Best to characterize cases by place of exposure

rather than by place at which cases reported
The two may differ and place of exposure is more
relevant to epidemiology of a disease

Example: travelers on a cruise ship exposed to a disease just

prior to disembarking but become symptomatic and are
diagnosed after return to various home locations
Example: person exposed to disease in small rural town but
referred to tertiary care center 100 miles away where
disease is diagnosed and reported

How to Conduct Surveillance:

Place Presenting Data

Data by geographic location can be presented

in a table
Also helpful to use maps to facilitate
recognition of spatial associations in data

See FOCUS Volume 5, Issue 2: Mapping for

Surveillance and Outbreak Investigation for
discussion of maps and visual presentation of
information

Inferential analysis can also be done using

multilevel modeling, other statistical methods

How to Conduct Surveillance:

Place Modeling Resources

Modeling of surveillance data by place is

beyond scope of this issue
Resources for further information:

Centers for Disease Control and Prevention.

Resources for creating public health maps.
http://www.cdc.gov/epiinfo/maps.htm. Updated
August 14, 2008. Accessed August 22, 2008.
Clarke KC, McLafferty SL, Tempalski BJ. On
epidemiology and geographic information
systems: A review and discussion of future
directions. Emerg Infect Dis. 1996; 2(2):85-92.

How to Conduct Surveillance:

Place Spot Maps

Spot maps: maps on which a dot or symbol marks a

case of disease
Made by indicating exposure locations of reported
cases of disease on hard copy map with pins or
colored pen
Or with geographic information systems (GIS)

Computer programs designed for storing, manipulating,

analyzing, and displaying data in a geographic context
Very useful for mapping surveillance data by place
Epi Map (part of Epi Info) can be downloaded for free at
http://www.cdc.gov/epiinfo to assist with map making

How to Conduct Surveillance:

Place Spot Maps

Example: spot map used to

show geographic spread of
cases in 1995 outbreak of
toxoplasmosis thought to be
associated with a municipal
water system in British
Columbia, Canada (5)

Spot maps show geographic

distribution of cases but not
population size at each
location, so should not be
used to assess disease risk

How to Conduct Surveillance:

Time

Compare number of cases reported in time

period of interest (weeks, months, years) to
number of cases reported during similar
historical period
Usually a delay (sometimes months to years)
between disease onset and date when
disease is reported, so preferable to use date
of onset, if available, rather than date of
report

How to Conduct Surveillance:

Time Line Graphs

Especially helpful for examining data not

likely to have much short term variation

Example: there is limited variation in number of

AIDS cases reported each month

Provide valuable qualitative information;

disease outbreaks often obvious from visual
inspection of data, may not require a
quantitative analysis

How to Conduct Surveillance:

Time Line Graphs

Example of line graph

using fabricated data:
reported cases of

Salmonella
typhimurium for 2-year

time intervals from

1974 to 2002
Spike in 1994
indicating outbreak of
S. typhimurium obvious
without quantitative
analysis

How to Conduct Surveillance:

Time Incidence Rates

May use line graph to plot incidence rates

Incidence rate is number of new cases that occur
during a specified time interval in a population at risk
for developing the disease

Number of new cases may be used as a proxy for overall

disease occurrence
Value often multiplied by 1,000 or 100,000 to improve
interpretability

Reporting incidence rates rather than numbers

particularly important if population has changed in
size or characteristics

Example: addition of towns to a surveillance region has

increased population size, or influx of migrant workers has
significantly changed the demographics

Standardization

Rate made up of numerator and denominator

Surveillance data often numerator data (number of
cases reported in time period)

Utility of these raw numbers is limited because do not take

into account size of population or distribution of
demographic factors such as age or gender

Rates allow more meaningful comparisons over time

within a population, among subpopulations, or
between populations

Rates take into account size of the population and time

period involved (3)

Standardization

Crude rates often calculated using surveillance data

Number of events of interest (such as reported cases
of disease) for a specific period of time for the entire
population
Only appropriate to compare crude rates if
populations are similar with respect to factors related
to disease of interest, such as age, gender, race

Example: would be inappropriate to compare rate of

prostate cancer in population with high proportion of elderly
men to rate in another population with mostly young men,
since risk of prostate cancer increases with age

Standardization

Standardization used to remove effects of differences

in confounding variables such as age when
comparing two or more populations

Results in adjusted rates

Is particularly useful when comparing rates in different
populations (e.g., comparing state data to national data)
when comparison of crude rates may be misleading if
populations differ on key variables

Most common technique uses weighted average rates

specific to potential confounding variables, based on
specified distribution of the variables (5)

Data Presentation

Surveillance data must be presented in way

that is easy to understand and interpret
Many ways to display surveillance data: (3)

Line graphs for displaying data by time

Maps for presenting data in geographic context
Graphical displays such as histograms, frequency
polygons, box plots, scatter diagrams, bar charts,
pie charts, or stem-and-leaf displays
Spot or chloropleth maps
Single/multivariable tables

Data Presentation

The choice of a particular graph or table

depends on type of data, but presentation
should be simple and easy to follow
Should provide all information necessary to
interpret the figure without referring to text
Include concise title that describes subject or
disease, time, place (when relevant)
Define any abbreviations or symbols
Note any data exclusions (3)

Data Presentation

Additional
display
guidelines
for tables
and graphs

Conclusion

Surveillance is valuable epidemiologic

tool that can serve many purposes
When surveillance data is collected,
analyzed, interpreted, reported
appropriately, these data can provide
important information about disease
patterns to inform public health practice
and policy

References
1.
2.

3.

Thacker SB, Berkelman RL. Public health

surveillance in the United States. Epidemiol Rev.
1988;10:164-190.
Thomas TN, Reef S, Neff L, Sniadack MM, Mootrey
GT. A review of the smallpox vaccine adverse
events active surveillance system. Clin Infect Dis.
2008;46 Suppl 3:S212-S220.
Janes GR, Hutwanger L, Cates Jr W, Stroup DF,
Williamson GD. Descriptive Epidemiology:
Analyzing and Interpreting Surveillance Data. In:
Teutsch SM, Churchill RE, eds. Principles and
Practice of Public Health Surveillance. New York,
NY: Oxford University Press, inc, 2000:112-167.

References
4.

5.
6.

Centers for Disease Control and Prevention. Active

Bacterial Core Surveillance Report (ABCs),
Emerging Infections Program Network,
Streptococcus pneumoniae, 2006.
http://www.cdc.gov/ncidod/dbmd/abcs/survreports
/spneu06.pdf2007. Published 2007. Accessed
August 21, 2008.
Last JM, ed. A Dictionary of Epidemiology. 3rd ed.
New York, NY: Oxford University Press, Inc, 1995.
Eng SB, Werker DH, King AS, et al. Computergenerated dot maps as an epidemiologic tool:
Investigating an outbreak of toxoplasmosis. Emerg
Infect Dis. 1999;5(6):815-819.