Components Of A Good Surveillance System And Future Plans .

Components of a good surveillancesystem and future plans for improvementin the EMRDr Amal BassiliStop TB unit, WHO, Regional Office for theEastern MediterraneanSurveillance Workshop,Cairo Sheraton,Cairo, Egypt, 27-29 October 20091

OverviewPublic health surveillance is the ongoingsystematic collection, analysis andinterpretation of outcome-specific data,closely integrated with the timelydissemination of these data to thoseresponsible for taking public health action toprevent and control disease or injuryThacker SB (2000). In: Principles and Practices of Public Health Surveillance. OxfordUniversity Press, New York. 1–16.2

Overview A health information system records and reportsinformation on the health of a population from avariety of demographic, logistical, programmemanagement and health-status indicators. The results are used for national health planning,policy-setting and targeted outcomes. Public health surveillance is an essential componentof the health information system with objectivesand methods that inform action for public health.3

From a presentation by Dr G Rodier, Director, Division of Communicable Disease Surveillance and Response, WHO at theWHO Global Consultancy on Surveillance meeting held in Geneva in October 2003.4

OverviewA functional surveillance system should:– have clear objectives;– use minimal relevant data collection for appropriateaction;– address a defined target population;– have specified sources of data (including health facilityrecords (public/private), laboratory results, case reports,surveys, and systems assessment reports); and– incorporate a well-identified information flow withfeedback and information-dissemination mechanisms inplace.5

Criteria of evaluating surveillance systems Surveillance systems are generally evaluatedaccording to the following ibility.Acceptability.Sensitivity.Positive predictive value.Representativeness (Completeness, Public/Private).Timeliness.Adequately resourced (cost of training, travel, supplies,equipment and services).6

Surveillance and Monitoring andEvaluationHealthInformationSystem7

Components of an effective surveillance/M&Esystems for TB control1) Presence of a sound M&E plan to document all thecomponents of the system:1. Structure, organization2. R&R tools3. Data flow4. Data quality assurance activities (data verification at all levels,supervision, quarterly meetings)5. M&E framework with indicators (Onion model)6. Relational Database (ENRS, Access, SQL, etc.)7. Human resources: surveillance officers with background inepidemiology; human resources development plan8. Coordination of activities9. Evaluation and research10. Challenges and ways forward811. Budgeted M&E workplan

Components of an effective surveillance/M&E systemsfor TB control2) Core capacities should be realized at each level for the detection, registration and reporting of data,local analysis, interpretation, action, laboratoryresponse, investigation, feedback, monitoring andevaluation.The focus of action and decision-making based on thesurveillance data should be at the local level (districtlevel).Each level of the health system – from the communityand health facility (public/private) to the district,provincial and national and international levels – hasa role in performing good disease surveillance and inusing information for action.9

Components of an effective surveillance/M&Esystems for TB control3) The provision of technical standards isessential for system efficacy – surveillance ismore effective when supported by standards,norms, guidelines, tools, training,communication systems, and adequatefinancial, human and material resources.10

Components of an effective surveillance/M&Esystems for TB control4) The provision of technical standards isessential for system efficacy –Detection of diseases and other public healthproblems is strengthened by the availability ofstandardized case definitions, disease-controlobjectives, reporting requirements andstandardized forms.Recording and Reporting tools (revisedR&R)11

Components of an effective surveillance/M&Esystems for TB control5) The provision of technical standards isessential for system efficacy – Systemefficiency requires clear reporting procedureson how to move data from one level to theother and methods for providing feedback tothe reporting units.Data flow12

Components of an effective surveillance/M&Esystems for TB control6) The provision of technical standards is essentialfor system efficacy – Data Quality Assurancethrough the following mechanisms: 1 Data verification at all levels 2 Supervisory visits with standardized checklistand feedback reports (copy distributed) 3 Quarterly meetings with objectives andguidelines13

Components of an effective surveillance/M&Esystems for TB control7) The presence of an electronic nominalRecording and Reporting system with thefollowing criteria:– Covering the 4 registers: suspects; lab; TB;contacts and their reports– Covering supplies management (drugs and lab);– Non-NTP and community R&R– Data quality verification mechanism withindicators– Quality: Completeness (reports/cells), timeliness,accuracy, consistency14

Components of an effective surveillance/M&Esystems for TB control8) Conducting Operational Research to– generate new knowledge (risk factor, risk groups, etc)– evaluate the impact of control measures by estimatingdisease burden (disease prevalence surveys, capturerecapture studies, vital registration, verbal autopsystudies, etc.)– evaluate gaps in programme performance and diseasecontrol– test new interventions such as new tools(vaccines/diagnostics/drugs/drug regimens); or newpublic health strategies (e.g. new PPM models)– Evaluate the impact of ACSM activities by conductingKAP studies– devise solutions: evidence-based public health actions 15

Components of an effective surveillance/M&Esystems for TB control9) Surveillance produces information that should belinked with public health action – this requires-Data analysis and interpretation of results-Qualified human resources (epidemiology/biostatistics/goodanalytical skills) Public health leaders and programme managersshould use the information to describe the locationand duration of problems, and the affectedpopulation. The result is evidenced-based decisionmaking that targets specific actions for control andprevention of public health problems.16

Public health actions linked to information obtained from publichealth surveillance activities in the field of tuberculosis controlSurveillance activitiesInformation obtainedPublic health actionRoutine quarterly case findingreports from district,intermediate to national leveland subnational analysis of dataEstimating the tuberculosisdisease burden in a country andannual trend of infection ordiseaseHigh default rateTrend of TB notification acrossspace (geographical/centres) andtime (over quarter/years)Investigating the reasons of anyinconsistency in notificationacross space and timeProgress towards theachievement of the Stop TBtargetsEnhanced programme activitiesin case of slow progressInadequate defaulter tracingmechanismLow rate of cases detected byother health care providers (nonNTP) whether by referral ofsuspects or diagnosis, treatmentand notificationUnavailability of informationabout the proportion of TBsuspects, defined a sufferingfrom cough for 2-3 week,identified in the outpatient clinics(OPD) of chest centers andSuboptimal engagement of theother health care providers intuberculosis controlInnovative intervention(s) tostrengthen treatment supportwith mobilization of requestedresources.Enhanced Public-Private MixMobilization of resources forthese activities.Inadequate tuberculosis suspectmanagement in the countryIntroducing the TB suspectregister in the OPD of the chestcenters and in the PHC andensuring testing all registeredsuspects-Mobilization ofresources for these activities.

Public health actions linked to information obtained fromoperational research activities in the field of tuberculosis controlOperational research activitiesInformation obtainedPublic health actionDisease prevalence surveys;capture recapture studies;VR/verbal autopsy studiesAccurate revised estimates of TBburden and determining trendsover time and space in TBburdenEvaluating progress towards thetargets with investigations toidentify the causes of increasedTB transmission , if annualincrease was reportedDrug resistance surveysThe burden and trends of drugresistance determined as well aspredictors of drug resistancePolicy change: e.g. Changecriteria for 1st line DST testingin case of increased transmission;strengthen DOT, etc.Active case finding amongcontactsThe incidence of TB amongcontacts reported (3-5% inseveral reports)To integrate ACD with PCD inthe routine programme activitiesfor the contacts that do not showupTesting new PPM modelEffectiveness and feasibility ofthe model reportedExpansion of the tested model inroutine programme activities

Situation and Future plansComponentsEMR1-M&E planAll GFATM supported countries have todevelop an M&E plan with technical supportfrom WHO2-Surveillance LevelAll NTPs have identified their reporting levelsbut not yet extended to all non-NTP andcommunity3-Technical standards: tools, guidelines,training manualsAll NTPs have developed their tools, guidelines, some have developed PPM guidelines andfew developed tools for communityparticipation4-Recording and reporting tools (revisedsystem)Few NTPs have introduced the revised R&R –commitment to introduce it by the end of20095-Data flowAll NTPs have identified their data flowsystems- but not yet extended to all non-NTPand community6-Data quality assurance systemWeak mechanisms of data verification,19supervisory visits, and quarterly meetings inmost of the countries

Thacker SB (2000). In: Principles and Practices of Public Health Surveillance . Oxford University Press, New York. 1–16. A health information system records and reports information on the health of a populat