Noncommunicable Disease

Surveillance in Public Health

Presenter’s Name
Presenter’s Title

Title of Event
Date of Event

Department of Health and Human Services

Centers for Disease Control and Prevention
 Learning Objectives
• Identify whether a noncommunicable disease
(NCD) surveillance system is active or passive
• Draw a diagram of the flow of data through an
NCD surveillance system
• Identify possible sources of selection bias and
information bias for an NCD surveillance
system

NCD Surveillance in Public Health 2

 Lesson Overview
• Role of surveillance in NCD public health
• Structure and function of public health
surveillance systems
• Operational aspects of surveillance systems
• Example of surveillance systems

NCD Surveillance in Public Health 3

 ROLE OF SURVEILLANCE IN
NCD PUBLIC HEALTH
NCD Surveillance in Public Health 4
 Definition of Public Health
Surveillance
“Systematic ongoing collection, collation, and
analysis of data and the timely dissemination of
information to those who need to know so that
action can be taken.”

– World Health Organization (WHO)

NCD Surveillance in Public Health 5

 How can surveillance
provide epidemiologic and clinical
information?
Establish baseline rate of disease and detect
increases
Estimate magnitude of a health problem
Determine geographic distribution
Understand the natural history
Generate hypotheses, stimulate research

NCD Surveillance in Public Health 6

 How can surveillance help
inform public health efforts?
Evaluate control measures

Monitor changes in chronic disease presentation

or infectious agents

Detect changes in health practices

Facilitate planning

NCD Surveillance in Public Health 7

 Examples of NCD Surveillance
Data
Diagnoses
• Type 2 diabetes
• Stage IV ovarian cancer
Conditions
• Screening results (e.g., elevated glucose levels)
• Overweight/Obesity
Lifestyle factors
• Smoking habits
• Dietary intake
• Physical activity

NCD Surveillance in Public Health 8

 Similarities of Infectious Disease
and NCD Surveillance
• Document prevalence of disease
• Document risk factors
• Can be used to describe time trends
• Can include a variety of data including:
_
Laboratory data
_ Self report data
_ Medical record data

NCD Surveillance in Public Health 9

 Obstacles to NCD Surveillance
• Lack of resources, infrastructure
_ Limited or no data collection mechanism
_
Limited data transmission capability
_ Lack of workforce training capacity
_
Limited availability of needed technology
• Low priority NCD or lack of political will to
address
• Unenthusiastic system participants

NCD Surveillance in Public Health 10

 STRUCTURE AND FUNCTION OF
PUBLIC HEALTH
SURVEILLANCE SYSTEMS 11
NCD Surveillance in Public Health
 Components of Surveillance:
Population
• National surveillance
• Specific to high-risk groups
_ Occupation
_ Health status (e.g., pregnancy clinics)
_ Geographic area

NCD Surveillance in Public Health 12

 Components of Surveillance:
Data Collection
• Health departments and/or organizations
_ Collect the data
_ Use forms for paper-based, fax, or emailed
reports
_ Mine data from electronic records
• Laboratory
_ Testing
_
Diagnosis

NCD Surveillance in Public Health 13

 Existing Data

Use of data already existing for other purposes

can help maximize resources.

Health management information systems

(HMIS)/administrative data
Vital statistics

NCD Surveillance in Public Health 14

 Research Surveys vs.
Public Health Surveillance
Research Surveys Public Health Surveillance

Hypothesis-testing Hypothesis-generating

One time On-going

Goes into depth Looks at broad trends and

within specific patterns across health
health issue issues, geographic areas

NCD Surveillance in Public Health 15

 Surveillance is a Cycle
• Data collection must be followed by data
analysis and interpretation
• Data analysis and interpretation must be
followed by dissemination of information
• Dissemination of information must be followed
by action/intervention
• Action/intervention must be followed by
repeating the cycle
Be wary of spending resources in one area of a surveillance system
without considering all of the system components

NCD Surveillance in Public Health 16

 Analysis, Interpretation,
Dissemination
• Surveillance System
_ Collate, process, analyze data
_ Monitor and interpret health indicators
_
Monitor system indicators and make
improvements
_ Create regular reports

MOH

NCD Surveillance in Public Health 17

 Surveillance System

Adapted from CDC’s Updated Guidelines for Evaluating Public Health Systems (CDC, 2011).

NCD Surveillance in Public Health 18

 Surveillance System
Stakeholders
• Participants in the system
• Users of the system
• Users of the results
• Public health practitioners
• Healthcare providers
• Community representatives
• Local, state, and national governments
• Nonprofit organizations
• Public
Engage stakeholders to ensure the system provides
useful information.
NCD Surveillance in Public Health 19
 OPERATIONAL ASPECTS OF
SURVEILLANCE SYSTEMS
NCD Surveillance in Public Health 20
 Priority Data Sources for NCD
Surveillance
• Vital registries
• Disease registries
• Ongoing periodic health surveys
• Administrative data
• Sentinel surveillance

NCD Surveillance in Public Health 21

 Types of Surveillance
Types of surveillance data collection
• Passive
• Active
Types of surveillance systems
• Population-based
• Sentinel

NCD Surveillance in Public Health 22

 Passive Surveillance Defined
“Passive” initial report for public health authorities
Most common type of data collection
• Healthcare providers and laboratories submit
standard forms
• Can rely on data collected for other reasons

NCD Surveillance in Public Health 23

 Passive Surveillance
in Use

NCD Surveillance in Public Health 24

 Active Surveillance Defined
Action required by local public health authority to
collect data
• Phone calls
• In-person visits

Requires more resources than passive

surveillance

NCD Surveillance in Public Health 25

 Active Surveillance in Use

NCD Surveillance in Public Health 26

 Population-Based Surveillance
• System accepts data from all providers and/or
laboratories in a country
• Sometimes involves a legal mandate for
providers and laboratories to report
(“reportable” or “notifiable”)
• Reporting forms are standardized by health
district or nationally
• Reporting accomplished through local
collection, passed through district/province level
to the national level
NCD Surveillance in Public Health 27
 Sentinel Surveillance
• Surveillance on a selected subset of potential sources
• Collection of data from a limited number of sites
_ Can be passive, active, or a combination
• Sites can be chosen to be representative of a population of
interest
_ Clinics
_ Hospitals
_
Laboratories
_ Individual providers
• Representative sample of cases is highly recommended

NCD Surveillance in Public Health 28

 Sentinel Surveillance in Use
• Useful if there is no existing surveillance system
or if one has been disrupted
• Can be expensive
• Difficult to ensure that selected sites are
representative of a larger population
• More information on risk factors can be
collected
• Example:
• Demographic Surveillance System

NCD Surveillance in Public Health 29

 Dissemination of Information
• To which groups of people should surveillance
results be distributed?
• Decision-makers (policy makers as well as
heads of surveillance, epidemiology, or public
health offices)
• Participating providers/reporters, colleagues
• The population under surveillance (the
community)

NCD Surveillance in Public Health 30

 Methods of Dissemination
• Decision makers
_ Reports, staff meetings,
conferences
• Participating providers
_ Weekly, monthly, or yearly
bulletins or summaries
• General population or public
_
Press releases, websites,
posters, radio
announcements,
community meetings

NCD Surveillance in Public Health 31

 Accuracy of Surveillance
• Bias: A systematic error in the collection or use of data
_
May lead to an over- or under- estimate of a problem
_
May lead to false conclusions
_
Incorrect conclusions may lead to misdirected public
health interventions

• Types of bias
_
Selection
_ Information

NCD Surveillance in Public Health 32

 Selection Bias
• Degree to which surveillance data do not
represent the population or geographic areas
• Method of accessing the population affects the
information gathered
_ Point of medical care vs. lack of resources or
availability to access care
_ Physicians or organizations which are easily
recruited vs. those that are representative

NCD Surveillance in Public Health 33

 Information Bias
• Degree to which the data obtained do not accurately
reflect the true values or measures
• Missing fields, especially those important to the topic
‒ Example: “Smoking” field is blank, especially
among smokers who may not want to admit to
smoking
• Question or field is open to interpretation
‒ Example: “Diagnosis” could be from the initial
doctor, the hospital discharge records, the
underlying cause of disease, or listed as cause
of death

NCD Surveillance in Public Health 34

 EXAMPLES OF NCD
SURVEILLANCE SYSTEMS
NCD Surveillance in Public Health 35
 Global Tobacco Surveillance
System (GTSS)
• Purpose is to enhance the capacity of countries to
design, implement, and evaluate their national
comprehensive tobacco action plan and to monitor the
key articles of the WHO Framework Convention on
Tobacco Control
• Countries choose to administer survey components
• Data collected through four surveys
• Aimed at youth, schoolteachers/administrators,
students in the medical field, and adults
• Each collects data about tobacco knowledge, attitude,
use, and/or intention to quit in the target population.

NCD Surveillance in Public Health 36

 GTSS Data Tool

NCD Surveillance in Public Health 37

 WHO STEPwise Methods
• STEPwise approach to Surveillance (STEPS)

• Simple, standardized method for collecting, analyzing,

and disseminating data in WHO member countries

• Risk factor assessment in three steps:

_ Questionnaire
• Demographic factors
• Lifestyle factors
_
Physical measurements
_
Biochemical measurements
NCD Surveillance in Public Health 38
 Example Studies Using
STEPwise Methods
• Combined prevalence of impaired glucose levels or
diabetes in Lusaka urban district, Zambia: a population
based survey
_
Recommended targeting young and middle-aged
adults for prevention-based interventions
• Alcohol consumption in Mozambique: Regular
consumption, weekly pattern, and binge drinking
_ Determined the pattern of current and binge drinking
according to education, gender, income

NCD Surveillance in Public Health 39

 REVIEW

NCD Surveillance in Public Health 40

 Review: Questions 1-4
1. What is the definition of surveillance?

2. What are the three components of surveillance

systems?

3. Give two examples of surveillance systems.

4. What are the two main data collection

methods?

NCD Surveillance in Public Health 41

 Review: Answers 1-4
1. What is the definition of surveillance? Surveillance is the systematic
ongoing collection, collation, and analysis of data, and the timely
dissemination of information to those who need to know so that action can
be taken.

2. What are the three components of surveillance systems? The population,

data collection, and analysis/ interpretation/ dissemination

3. Give two examples of surveillance systems. There are many acceptable

answers, but the Global Tobacco Surveillance System and WHO
STEPwise were featured in the lecture.

4. What are the two main data collection methods? Active and passive data
collection methods

NCD Surveillance in Public Health 42

 Review: Questions 5-6
5. Describe the cycle of surveillance.

6. What is the difference between population-

based surveillance and sentinel surveillance?

NCD Surveillance in Public Health 43

 Review: Answers 5-6
5. Describe the cycle of surveillance. Surveillance begins at the
population level with the detection of a health event by medical
care providers and laboratories. These entities report to health
departments, where data collation, cleaning, analysis, and
interpretation takes place. Reports are then disseminated back to
the stakeholders in the system, including health departments,
reporters, and the population.

6. What is the difference between population-based surveillance and

sentinel surveillance? In population-based surveillance, all
providers and/or laboratories in the country report and data is
collected at the local level. In sentinel surveillance, surveillance is
on a selected subset of potential sources; sites can be chosen to
be representative of a population of interest.

NCD Surveillance in Public Health 44

 Review: Questions 7-8
7. What is bias?

8. What is the difference between public health

surveillance and research surveys?

NCD Surveillance in Public Health 45

 Review: Answers 7-8
7. What is bias? When looking at surveillance data, bias is
an inaccurate representation of cases occurring in the
population under surveillance in those data.

8. What is the difference between public health

surveillance and research surveys? Public health
surveillance is hypothesis-generating, focuses on
multiple health issues, and looks at broad trends and
patterns across health issues and geographical areas.
Research surveys are hypothesis-testing, focus on
specific health issues, and go into depth within those
specific health issues.
NCD Surveillance in Public Health 46
 Skills Assessment
1. You will work in small groups to assess a given
NCD surveillance system in terms of structure
and design.
2. All group members should keep notes, but
assign one group member to record official
responses.
3. Spend no more than one hour completing the
assignment.
4. Be prepared to share your work with the class.

NCD Surveillance in Public Health 47

 Centers for Disease Control and Prevention (CDC). NCD
Surveillance in Public Health. Atlanta, Georgia: Centers for Disease
Control and Prevention (CDC); 2013.

NCD Surveillance in Public Health 48

 For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.

Department of Health and Human Services

Centers for Disease Control and Prevention 49