Module 8

Public Health Surveillance (PHS) and

Early Warning System (EWS)
 Learning outcomes
• At the end of this module, students should be able
to:
– Describe what Pubic Health Emergency Management
(PHEM) constitutes
– Describe objectives and approaches of Public Health
Surveillance (PHS)
– Explain core activities of PHS
– Explain the components of Early Warning System (EWS)
– Describe the flow of data and information in the
different levels of health system (HS)
Public Health Emergency Management (PHEM)

• PHEM is designed to ensure rapid detection of any

public health threats, preparedness related to logistic
and fund administration, and prompt response to
and recovery from various public health
emergencies.
• PHEM is the process of anticipating, preventing,
preparing for, detecting, responding to, controlling
and recovering from consequences of public health
threats in order that health and economic impacts
are minimized.
• The process is fully integrated, adaptable, all-hazards
and all health approach national preparedness and
response system.
• This core process is comprised of four sub processes
which are:
– Early Warning, (EWS), Public Health Emergency
Preparedness, (PHEP), Response (PHER), and Recovery
(PHER).
• Every public health emergency management
processes have a starting and ending point.
– The process starts with early warning and ends with
recovery.
– However, in real situation the steps move forwards and
backwards.
Figure: PHEM core process sub-process
• Guiding principles
– Multi-hazard approach
– From risk assessment to recovery
– Risk assessment and mitigation (shift from disease
management to risk assessment (Vulnerability-
Hazard and risk assessment)
– International Health Regulations (IHR2005)
• International Health Regulations (IHR2005)
– The PHEM process considered and encompassed
international obligations that Ethiopia ratified
– The IHR 2005 is a legally binding document that entered
into force on 15 June 2007.
– The purpose of the IHR 2005 is to prevent, protect against,
control and provide public health response to the
international spread of disease in ways that are relevant
and restricted to public health risks, and which avoid
unnecessary interference with international traffic and
trade.
– The scope of the regulation embraces all the public health
emergencies of international concern (PHEIC), which
includes those caused by infectious diseases, chemical
agents, radioactive materials, and contaminated food.
• The three main categories of events that require to
be notified under the IHR 2005 are:
– Four conditions that must be notified to WHO:
– smallpox,
– poliomyelitis due to wild type poliovirus,
– human influenza caused by a new subtype, and
– severe acute respiratory syndrome.
– Other diseases and events may require
notification if they are considered to be events of
potential international public health concern.
– cholera,
– plague,
– yellow fever,
– viral hemorrhagic fever,
– other diseases that are of special national
concern.
– Any event of potential international public health
concern including those of unknown cause or
source, and those involving other events or diseases
than those listed in the above two bullet points.
• Notification may be required for:
– Events, irrespective of their origin or source, including
those caused by biological, (both of an infectious and non-
infectious nature) chemical agents or radio-nuclear
materials;
– Events where the underlying agent, disease or mode of
transmission is new, newly discovered or as yet unknown
at the time of notification;
– Events involving transmission or potential transmission
through persons, vectors, cargo or goods ( including food
products) and environmental dispersion;
– Events that carry potential future impact on public health
and require immediate action to reduce the
consequences;
– Events arising outside of their established patterns of
occurrence.
 Surveillance
• Is the process of gathering, analyzing, and
dissemination of information for the purpose of
proper planning, implementation, and evaluation of
health services/interventions.
• It is also defined as Information for Action.
• A functional disease surveillance system is essential
for defining problems and taking action.
• Objectives of surveillance:
– to detect epidemics/outbreaks so that they can be
controlled in a timely manner,
– to predict epidemics so that health services can plan to
respond, prevent where possible, treat and control priority
diseases,
– to monitor trends of priority diseases in order that
changing trends inform policy decision,
– to evaluate an intervention so that effective and efficient
actions/policies are identified and supported.
 Approaches to public health surveillance

• Based on type of methods used for collecting the

necessary data,
1. Passive surveillance

2. Active surveillance

– Sentinel surveillance

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 Elements of surveillance system
• Surveillance systems are often considered as
information cycles involving different components of
the community.

Public

Reports
Summaries, Health Care
Interpretations, Providers
Recommendations
Health
Agencies

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 Surveillance activities
◦ Detection,
◦ Collection (Registration)
◦ Confirmation (epidemiological and laboratory confirmation)
◦ Reporting (early warning)
◦ Analysis and interpretation (detecting outbreaks, changes in
disease patterns)
◦ Response (preventive and control measures, outbreak
investigation, program adjustment, changes in policy and
planning)
◦ Feedback, Evaluation and monitoring
◦ Dissemination
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 Early warning
• Definition: Early warning is the identification of a public
health threat by closely and frequently monitoring identified
indicators and predicting the risk it poses on the health of the
public and the health system.
• Purpose: enable the provision of timely and effective
information to the public and to responders, through
identified institutions that allow preparing for effective
response or taking action to avoid or reduce risk.
• Public health early warning indicators:
Conditions which, when they occur or change, signal an
increase in the risk of occurrence of a particular threat to
public health. These indicators are regularly monitored to
identify situations for which a public health action may be
needed.
 Major indicators of early warning
• An increase in the number of cases beyond expected
• Un explained morbidity and mortality,
• Malnutrition,
• Evidence of increase in zoonotic disease and/or vectors,
• Environmental changes, contamination (air pollution, water
quality changes, contamination),
• Drought, flood, severe weather (metrological information),
• Agricultural events such as reduced harvest, occurrence of
pests or diseases,
• Refugees, internally displaced people, disruption of health
services and infrastructure,
• Important industrial accidents; chemical spills etc.
Figure: components of early warning system
Components of early warning system
• 1.1. Indicator-based Surveillance (IBS):
– refers to structured data collected through routine
integrated disease surveillance, nutritional and laboratory
surveillance.
• 1.2. Integrated Disease Surveillance (IDS)
– In integrated disease surveillance, the various surveillance
activities become integrated into one system within the
broader national health system.
– It also emphasizes all functions of surveillance activities to
be carried out using similar structures, processes and
personnel.
• 1.2.1. Identifying Priority Diseases and
Conditions for Surveillance
– It is clear that surveillance could not be carried out for all
diseases and conditions.
– Therefore, priority should be given to those diseases that
are of interest at national and international levels.
– In Ethiopia 20 diseases (13 are immediately reportable
whereas 7 are weekly reportable) are selected to be
included into the routine surveillance.
• Diseases and conditions selection criteria:
1. Diseases which have high epidemic potential
2. Required internationally under IHR2005
3. Diseases targeted for eradication or elimination
4. Diseases which have a significant public health
importance
5. Diseases that have available effective control
and prevention measures for addressing the
public health problem they pose.
Table: reportable diseases/conditions in Ethiopia
• There are also emergency illnesses or health
conditions that are of concern to the public which
need early response
– Cluster of rash illness,
– Hemorrhagic illness,
– Botulism-like syndrome,
– Sepsis or unexplained shock,
– Febrile illness (illness with fever, chills or rigors),
– Disease caused by antimicrobial resistant organism,
– Non-traumatic coma or sudden death,
– etc
• 1.2.2. Standard Case Definitions
– Case definition: is a set of criteria used to decide if a
person has a particular disease, or if the case can be
considered for reporting and investigation
– Standard case definition: is a case definition that is
agreed upon to be used by everyone within the country.
Standard case definition can be classified as confirmed,
probable, and possible or suspected.
• Reading assignment (PHEM guideline on page 24):
– standard case definition of suspected and confirmed cases
of the 20 reportable diseases and conditions listed in table
– simplified case definitions for community levels
• 1.2.3. Reporting diseases and conditions
under surveillance
– Ensuring reliable reporting of surveillance data throughout
the country
– The routine flow of surveillance data is usually from
reporting sites to the next level up to the central level.
– Electronic reporting: IDS and Health Management
Information System (HMIS) uses software at different
levels, the lowest being at health center level.
– Reporting Periodicity: immediately and weekly (verbally,
telephone, radiophone, email, fax, mobile SMS).
Figure: formal and informal flow of data and
information throughout health system
• Reporting Tools: tools utilized at different levels of the
health system.
– Weekly reporting form for health post / HEW
– Weekly reporting format f or other levels
– Daily epidemic reporting format for Woreda(DERF-W)
– Daily epidemic reporting format for Region(DERF-R)
– Case based reporting format (CRF) for many diseases
– AFP case investigation form
– Guinea worm case based reporting format
– Guinea worm line list
– Influenza case based reporting format
 – Line list(for all diseases)
– Rumor log book for suspected epidemics (for any type
of public health rumors)
– Case based laboratory reporting form (CLRF).
• Reporting Procedures: PHEM guideline page 32-33
– Reporting of the identified disease is either immediately or
on weekly bases using their own reporting formats.
– During epidemics the reporting procedures varies from the
routine reporting
– Number of cases to be reported varies based on type of
disease
• For example:
– All suspected cases of AFP (Acute Flaccid Paralysis) should
be reported using the case based format specific for AFP
– Report the first 10 cases of suspected meningitis cases
during the epidemic using the Case-based Reporting
Format.
– Report all confirmed or suspected cases of meningitis on
weekly basis.
– If epidemic threshold is surpassed then start reporting on
daily basis using Daily Epidemic
– Reporting Format for Woreda (DERF-W) and Daily
Epidemic Reporting Format for Regions (DERF-R).
Figure: format to be used for different levels of health system)
• 1.3. Laboratory-based surveillance (LBS)
– is the key part of the overall surveillance as the detection
and control of outbreaks requires rapid identification of
the pathogens and their source of infection.
– Starting from the national level to the health post level,
suspected outbreaks should be confirmed by laboratory
investigation.
– The purpose of the public health laboratory
network is to improve the performance of
laboratories in support of disease surveillance and
response.
 Table: type of sample where lab can be done
Name of disease Sample type Examine samples at

Dracunculiasis/ Worm National Laboratory (EPHII) (To

Guinea worm be sent abroad)
Measles • Blood (serum) • National Measles Lab (EPHI)
• Throat swab (during • Regional Lab
epidemics)
Pandemic influenza A Throat Swab National influenza Lab (EPHI)
Rabies Tissues from cerebellum Zoonosis diseases laboratory
and brain stem from (EPHI)
animals to confirm

Smallpox, VHF, Yellow fever Blood (sample) • National lab (EPHI) (to be
sent abroad)
SARS Throat swab
• Smallpox (to be sent abroad)
 Table: type of sample where lab can be done
Name of disease Sample type Examine samples at
Acute flaccid paralysis (AFP) Stool National polio lab (EPHI)

Cholera Stool Regional Lab

Anthrax • Cutaneous : Swab from Zoonosis diseases Lab
vesicular lesion
• Gastro Intestinal: Blood
for culture and stool
• Respiratory/inhalational
: Sputum
Avian human Influenza • Throat Swab • National Influenza
Laboratory (EPHI)
Dysentery Stool Health post, health center,
Malaria, typhoid, RF, Blood, CSF (meningitis) hospital labs
meningitis, typhus
• 1.4. Event-based Surveillance (EBS)
– Event-based surveillance is the organized and rapid
capture of information about events that are potential risk
to public health.
– This information can be rumors and other adhoc reports
transmitted through normal channels (i.e. established
routine reporting systems) and informal channels (i.e.,
media, health workers and nongovernmental organizations
reports, etc.)
• Event-based surveillance encompasses the following
two areas:
– Events related to the occurrence of disease in humans
– Events related to potential risks for humans health
• EBS complements IBS and relies on the immediate
reporting of events and help to detect:
– rare and new events not specifically included in indicator-
based surveillance.
– events that occur in populations which do not access health
care through formal channels.
• Sources of information for EBS
– Media
– Health care workers
– Community members
– Scientific findings related to new organisms, drug resistance,
etc
– Agriculture, environment, meteorology
– International watch (report and websites )
– etc
• Surveillance Data Analysis and Interpretation
– Organize the Data
– Create an electronic database or file paper data
– Data cleaning
– Analysis data by person, place, and time
• Trends over time(line graph, bar graph or histogram),
• Geographic distribution of the disease or the outbreak
(dot map),
• Frequency of cases, deaths (table),
• Case fatality rate (CFR),
• Attack rate (AR).
• Interpret the analyzed data
• Compare the current situation with previous
week/months/quarter, seasons and years:
– Observe the trends on the line graphs and look to see
whether the number of cases and deaths for the given
disease is stable, decreasing or increasing.
– If case fatality rates have been calculated, is the rate the
same, higher, or lower than it was in the previous months.
– Determine if thresholds for action have been reached or
crossed.
• Thresholds:
– are markers that indicate when something should happen
or change.
– help surveillance and program managers answer the
question, “When will you take action, and what will that
action be?”
• Thresholds are based on information from two
different sources:
• A local situation analysis for the specific disease or
condition
• International recommendations from technical and
disease control program experts.
• Two types of thresholds:
– alert threshold: suggests to health staff that further
investigation is needed and preparedness activities should
be initiated. Health staffs respond to an alert threshold

– action threshold : triggers a definite response. It marks

that the findings from either the routine surveillance or
special investigation signal the need for action beyond
confirming or clarifying the problem
Table: Threshold levels for declaring an epidemic for
diseases under surveillance
Table: Threshold levels for declaring an epidemic for
diseases under surveillance
• Summarize the analysis results
– Increase or decrease in number of cases…why?
– If no decrease while undertaking health
intervention…what factors you should consider?
• Communicate the Information
– Risk communication
– Decide what to communicate
– Decide how to state the message
– Use appropriate communication methods
– Meet with the community spokesperson regularly
• Provide feedback