BASIC EPIDEMIOLOGY, OUTBREAK INVESTIGATION AND DATA MANAGEMENT AND ANALYSIS

TRAINING FOR HESUs OF NORTH COTABATO

NOTES

August 8, 2023

LESSON 1.01: Introduction to Basic Epidemiology

Objective:
1. Describe steps of the public health surveillance cycle

Public Health Surveillance

Ongoing and systematic approach in collecting, analysis, interpretation, and timely dissemination
of health-related data for the use in public health action to reduce morbidity(disease) and mortality and
to improve health.
It requires multilevel collaboration form health care provider to district to national to
international

Cycle of Health Surveillance:

Detect/diagnose – Collect – Compile, analyze – Interpret – Communicate – Take action

Detect/Diagnose:
WHAT: What to report based on case definition (Personnel must know what are the notifiable diseases
based on case definitions)
WHO: Who will report? Everyone should report any Notifiable diseases as stipulated by law.
Collect:
Collect data/ health information
Collect samples/ specimens
Report a case/ health event to the next higher ESU (CIF/CRF)
Compile/ Analyze
Consolidation of data (person, place, time)
Validated, accurate and complete report

Interpret
Systematic process to determine trends, spikes, outbreaks, reached alert or epidemic threshold
Hospital setting: increasing/decreasing/plateau

Some uses of Public Health Surveillance

 Describe the burden of or potential of disease

 Monitor trends and patterns of disease, risk factors and agents
 Detect sudden changes in disease occurrence and distribution
 Provide data for program, policies, and priorities
 Evaluate prevention and control measures

Surveillance is used to:

Portray patterns of health-related conditions and events to:

 Assess public health status

 Trigger public health action
 Define public health priorities
 Evaluate programs

Lesson 1.02: Legal Basis and Policy

Common ethico-legal issues on Public Health Surveillance

 Privacy
 Confidentiality
 Consent
  Discrimination
 Stigma

Key Legal basis and Policy of PH Surveillance

RA 11223 – Universal Healthcare Act

 Contains progressive and comprehensive reforms that will ensure every Filipino is healthy,
protected health hazards and risks, and has access to affordable, quality
 IRR: Rule IV Section 17; The DOH shall endeavor to contract province-wide and city-wide
health systems for the delivery of population-based health services.
 Minimum components: Primary care provider network with accessible patient records;
Epidemiologic surveillance system
RA 11332 – Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern

 Aims to protect the people from public health threats through the efficient and effective
disease surveillance
 Enacted in April 2019
 IRR circulated in April 2020
Section 1. Priority diseases
a. Disease spread by droplet
b. Airborne diseases
c. Diseases spread by direct
d. Vehicle-born diseases
e. Vector-borne diseases
Section 3. Criteria for inclusion

 International or national concern

 Has epidemic or outbreak potential
 Being eliminated
 One of the 10 leading cause of morbidity and/or mortality
 Large number of serious or long term disabilities
 Large Number
 Characteristics, prevalence, incidence and/or mortality is changing and would likely impact
public health
 Priority of DOH
 Fulfills either one of the surveillance goal
Section 3. Criteria for Exclusion

 Not considered a public health risk or threat

 Has no epidemic or outbreak potential
 Has been eliminated or controlled
 No longer included in the top 10 leading causes of morbidity and/or mortality
 Low to no incidence or disability or residual complication
 Low risk for mortality
 Characteristics, prevalence, incidence and/or mortality consistently low, or no public
health impact
RULE V. Section 1. Official List of Institutionalized Systems

 Hospital Sentinel Surveillance System

 FHSIS
 PIDSR, with its case-based surveillance and Event-based surveillance
 Community-based disease Surveillance system
 Quarantine HSIS
 Laboratory Surveillance System
RULE VI. Section 2. Persons and Entities Required to do Mandatory reporting

 Licensed Public and Private medical and allied health professionals

 Health facilities and offices
 Workplace
 Educational Institutions
 Prisons, jails
 Accommodation Establishments
 Communities
 Professional societies, civic organization and other non-government organization
RULE VIII. Section 1. Processing of information
Data collection, analysis, dissemination of information shall be done by authorized personnel
from DOH

Section 2. Disease Surveillance duty of DOH

DOH shall ensure that epidemiology and surveillance capacity is treated as an essential service
DOH Order No. 2021-0057 – Revised Guidelines on the Philippine Integrated Disease Surveillance and
Response
Lesson 1.02: Collecting Surveillance Data

Passive vs Active Data Collection

Passive

 Relies on others
 Healthcare provider initiates
 Usually adequate for monitoring trends over person, place, and time
Active

 Requires assertive action

 Health agency solicits information
 Usually reserved for diseases of special interest

Aggregate vs Case-based reporting

Aggregate

 Combined number of cases

 By age, sex, etc
 Weekly or monthly
Case-based

 Each case reported individually

 Line list or case report

Zero Reporting
Report of zero cases when no cases are observed within a specific time frame

 Distinguishes between report

Role of Laboratory

 Laboratories are important public health partners in a district

 Laboratory confirmation is essential to:
 o Rule in or diagnose a specific disease
o Rule out a specific disease
o Confirm a case of a reportable disease
o Verify the cause of a suspected outbreak

Accurate laboratory results require a specimen that is:

 Collected at the proper time during a persons’ illness

 Collected from the proper source
 Placed in the correct transport media
 Handled, stored and transported properly

Reporting Sources

 Health care providers

 Laboratories
 Pharmacists
 Media reports
 Sick persons, family, neighbors
 Others

Case-based Surveillance: Information on a Case Report Form

 Identifying Information
 Demographic information
 Clinical information
 Exposure and risk factor information
 Reporter information
 Contacts and other

Limitations of Reporting Systems

 Underreporting, incomplete reporting

 Lack of representativeness of reported cases
 Lack if timeliness
 Inconsistent use of case definitions

Ways to improve reporting

  Improve awareness
 Reduce reporting burden- simplify reporting, conduct active surveillance
 Monitor, conduct site visits
 Provide feedback through reports
Summary:

 Public health surveillance begins with data collection

 It is based on laws and regulations
 Data collection can be active or passive
 Underreporting is common and can lead to poor decisions
 Feedback is an important positive reinforcement
 Monitoring and evaluation can help address underreporting.

Lesson 1.03: Case Definition and Line List

Case Definition
A uniformly applied set of criteria for deciding whether to classify a person as having a particular
disease, injury, or other health related condition

Application

 Clinical Diagnosis
 Surveillance
 Outbreak investigation
 Analytic studies

Ex. Case definition of Cholera

In an area where disease is not known to be present
-Suspected case
 Patient > 5 years of age with severe dehydration or death from acute watery diarrhea
-Confirmed case
Vibrio cholerae 01 or O139 is isolated from any patient with diarrhea.

Purpose of Surveillance Case Definition

 To determine whether the case should be reported

Characteristics
a. Usually focus on clinical features
a. Symptoms
b. Signs
c. Laboratory result
b. Some include demographic criteria
c. Many are tiered

Line List
Table used for public health surveillance or epidemiologic investigation that includes
demographics

Day 2: August 9, 2023

Lesson 1.04: Data Quality

Data Quality
The level of accuracy and completeness of data in a dataset

 Do the data accurately reflect reality, so that the data serve the intended purpose
 High quality data more likely to lead to better decision-making and planning
Examples of Data quality issues
Individual records

 Missing Data
 Incorrect data
 Unreadable data
Data systems

 Delayed records
 Missing records
 Duplicate records

Common type of Data entry Error

 Transposition
 Copying
 Coding
 Consistency
 Range

Causes of Poor data quality

1. During data Collection

 Poorly designed forms
 Patient inability or refusal to provide information’
 ‘Language barriers
 Health provider inability or refusal to collect data
 Missing or inaccurate facility records
 Late collection and/or reporting
2. During data entry, Management, analysis
 Transcription errors
 Calculation errors
 Data handling errors (lost data, lost files, wrong files)
Impact of Poor Surveillance Data Quality

 Distorted picture of disease occurrence

 o Missed diseases of public health importance
o Missed outbreaks
o Misdirected resources
o Reduced request for resources

Inadequate monitoring and evaluation program effectiveness

Reduced confidence and support

Steps to promote better data quality

o Use standardized forms, procedures and terms
o Distribute written guidelines to all reporting sites
o Provide training on importance of surveillance and surveillance practices
o Conduct regular data quality audits
o Give consistent and timely feedback to facilities

Measures of Central Location

Single measure that represents an entire distribution

Mean
o Use all data; sensitive to outliers
o Mean preferred for symmetrical data; not common in epidemiology

Median

 Safer choice for most epidemiologic data

Mode
Most common value

 Use median or mean with range

Counts
1. Common descriptive measure
 2. Provides picture of burden of disease
3. Essential for service delivery or planning
4. First step in calculating rates

Proportion
Comparison of a part to the whole
Useful for describing distribution of characteristics within a population

x/y where
x= is the number with a characteristic
y=total number

Incidence- new cases

Prevalence- current cases

Incidence rate- is the frequency of new cases of illness in a population over a specified period of time

Attack rate

Number of new cases during specified period x constant

Size of population at the start of that period

Lesson 1.06: Displaying data

Why organize and display data?

 Summarize when dataset has too many records to review individually

 Become familiar with the data before analysis
 Identify and display
o Pattern
o Trends
o Relationships
o Exceptions and outliers
 Communicate information to others

Types of tables

1. 1-variable table (frequency distribution)

a. Range of values of a single variable
b. Variable of observations with each value
2. 2-variable table

What can account for an apparent increase in cases

1. True increase in disease occurrence
 Outbreak/epidemic
 Seasonal pattern
 Sudden increase in size population
2. Change in reporting procedures
3. Change in case definition’
4. Increase or improvement in laboratory testing
5. Increased access to healthcare
6. New healthcare provider, reporter or clinic
7. Laboratory or diagnostic error
8. Batch reporting

August 10, 2023

Lesson 1.08: Communicating Surveillance Information

Communicate with whom?

Two-way communication with:

 Healthcare providers
 Public health laboratory work
 District Public Health Office
 Provincial/City Public Health Office
 Central Ministry of Health
o Program managers
o Decision-makers
 General Public

Communicate What?

 Summary of disease surveillance data

 Alerts about outbreaks and other unusual events
 Monitoring and evaluation feedback
 Changes in disease reporting

Communicate how?

 Phone
 Text/SMS
 Fax
 Paper
 Email
 Press release
 Website posting
 Social network
 Online submission
 Face to face

Communicate when and how often?

 Immediately
  Weekly
 Monthly
 Annually
 During a response to a public health emergency

Why routine communication (What are the benefits?)

 Show patterns, trends, and unexpected changes

 Demonstrate that district reviews (values) reports
 Transparency promotes goodwill
 May identify data quality issues
 Provides data for program planning
 Establishes links for emergency communication

Routine communication
1. Periodic reports
a. Weekly tables, graphs
b. Monthly/ quarterly summaries

Communication supports preparedness

Emergency preparedness:
Maintaining communication channels with updated contact information can facilitate:

 Early recognition and prompt reporting of possible disease outbreaks or epidemics

 Enhanced teamwork in response to actual outbreaks

Lesson 1.12: SWOT Analysis

Lesson 1.10: Surveillance Monitoring and Evaluation

What are Monitoring and Evaluation

Monitoring

 Ongoing systematic review of the key steps of surveillance process

Evaluation

 Episodic assessment of performance of surveillance system measured against established

criteria
 Occasional

Characteristic of a Well-functioning Surveillance System

 Reportable diseases are recognized and reported according to policy

 Case-based, weekly and monthly reports are complete, timely and accurate
 Reported data are promptly and properly analyzed and interpreted
 Surveillance findings shared to inform public health action, policy and program management.

Indicators and targets:

Attributes: Timeliness of reporting

Indicator
Measure of key aspect or attribute of surveillance system
Ex: Percent of facilities sending wekkly report within 2 days of end of reporting week

Target
Performance goal for indicator
 Ex. 80% of facilities send report

Timeliness
Surveillance report arrive at next level on schedule

Completeness

 Surveillance reports