WHO CDS EPR LYO 2006 2 Eng
WHO CDS EPR LYO 2006 2 Eng
World Health Organization 2006 All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
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1.1 Background 1.2 Purpose of the monitoring and evaluation guide 1.3 Intended users 2 Overview of monitoring and evaluation of surveillance & response systems
2.1 Principles of monitoring and evaluation of surveillance and response systems 2.2 Indicators as tools for M & E
2.2.1 2.2.2 2.2.3 Qualities of a good indicator Types of indicators in the logical framework approach Selection of indicators
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3.1 Priority diseases targeted for surveillance and response 3.2 Structure of the system
3.2.1 3.2.2 3.2.3 3.2.4 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5 3.3.6 3.3.7 3.3.8 3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.4.5 3.4.7 3.5.1 Legislation for surveillance Surveillance strategy Implementers and stakeholders Networking and partnership Case detection Case registration Case confirmation Reporting Data analysis and interpretation Epidemic preparedness Response and control Feedback Standards and guidelines Training Supervision Communication facilities Resources Monitoring and evaluation Coordination Completeness i
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Timeliness of reporting Usefulness of the surveillance data and the surveillance system Simplicity of the system Acceptability of the system Flexibility of the surveillance system Sensitivity in surveillance Specificity in surveillance Positive predictive value Representativeness of the surveillance system
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4.1.1 4.1.2 4.1.3 4.1.4 4.1.5 4.1.6
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5.3 Conduct the evaluation 5.4 Dissemination and use of evaluation results Bibliography Annex 1
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Key definitions in M & E Annex 2 Summary of existing communicable disease surveillance guidelines Annex 3a Template to guide identification and development of M & E indicators for communicable disease surveillance systems Annex 3b Abbreviations used in the tables in Annex 3c: Annex 3c Proposed list of Indicators for M & E Component: Annex 4 Methods of data collection for M & E 4.1 Sources of data for monitoring and/or evaluation 4.2 Data collection methods
4.2.1 Checklist for feasibility of data collection methods
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4.3 Performance questions and indicators 4.4 Quantitative methods of data collection
4.4.1 4.4.2 4.4.3 4.4.4 4.4.5 4.4.6 4.5.1 4.5.2 4.5.3 4.5.4 4.5.5 Questionnaires and surveys Case studies Direct observation Periodic analysis of routinely-collected data Review and analysis of hospital discharge records Capture and recapture method Supervision Surveillance meetings and workshops Document review Focus group discussions Key informant interviews
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Acknowledgements
This Guide was prepared by the Epidemiological Surveillance Strengthening Team of the WHO Lyon Office for National Epidemic Preparedness and Response, with financial support from the United States Agency for International Development (USAID) Bureau for Global Health, and with contributions from the following individuals:
Technical Partners
Ms Helen Perry, Senior Training Specialist, IDSR Team Leader, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Dr Peter Nsubuga, Medical Epidemiologist, Division of International Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Dr Sambe Duale, Senior Research Manager and Infectious Disease Advisor, Support for Analysis and Research in Africa, Washington, DC, USA Field Epidemiology Training Programme Dr Mahomed Said Patel, Fellow, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
Ministries of Health
Dr Sok Touch, Department of Communicable Disease Control, Ministry of Health, Cambodia Dr Nada Ghosn, Epidemiological Surveillance Unit, Ministry of Public Health, Lebanon Dr Ambrose Talisuna, Epidemiological Surveillance Division, Ministry of Health, Uganda
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
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Guide to monitoring and evaluating communicable disease surveillance and response systems
Introduction
1.1 Background
Surveillance is the ongoing systematic collection, analysis, and interpretation of outcomespecific data for use in planning, implementing and evaluating public health policies and practices. A communicable disease surveillance system serves two key functions; early warning of potential threats to public health and programme monitoring functions which may be diseasespecific or multi-disease in nature. The early warning functions of surveillance are fundamental for national, regional and global health security. Recent outbreaks such as the severe acute respiratory syndrome (SARS) and avian influenza, and potential threats from biological and chemical agents, demonstrate the importance of effective national surveillance and response systems. The International Health Regulations (IHR) 2005 underscore the commitment to the goal of global security and request all Member States to establish and implement effective surveillance and response systems to detect and contain public health threats of national and international importance. The programme monitoring function of surveillance of communicable diseases encompasses a variety of goals such as eradication or elimination (e.g. of guinea worm, measles) and surveillance for acute flaccid paralysis. Surveillance systems also serve to monitor trends of endemic diseases, progress towards disease control objectives, and to provide information which may be used to evaluate the impact of disease prevention and control programmes. All Member States should enhance their national surveillance systems for communicable diseases in order to meet the various objectives. A structured approach to strengthen national communicable disease surveillance systems could include: Assessment of communicable disease risks to identify major public health threats. Prioritization of public health threats to ensure that surveillance is limited to the important public health events. Assessment of existing systems to review strengths, weaknesses, and opportunities for strengthening the systems. Development of a strategic plan of action based on the findings of the assessment. Implementation of activities planned to strengthen the systems. Monitoring progress in implementation of planned activities, the evolution and performance of the surveillance system. Evaluating outcomes and overall impact of the surveillance system.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Figure 1
Guidelines have been developed to support implementation of the various steps shown in Figure 1. Annex 2 contains a list of some of the currently-available WHO guidelines. This Guide has been developed to support implementation of monitoring and evaluation of communicable disease surveillance and response systems at country level. It was reviewed by experts in communicable disease surveillance and response systems, and pre-tested in Estonia and Ethiopia.
1.2
As the momentum to scale up the global response to communicable diseases increases, public health practitioners need to constantly review their performance in detecting and responding to communicable diseases. At the same time, they should account for the planned activities, policies and resources to a variety of stakeholders. The staff working at different levels of surveillance need to report accurate data in a timely manner to the next higher level to ensure timely and effective responses to contain communicable disease outbreaks. They may be required to report on progress to partners and donors, but most importantly, surveillance information should be used locally to address and resolve problems related to control of communicable diseases and to strengthen evolving programmes. Monitoring and evaluation are keys to establishing and maintaining effective and efficient surveillance and response systems. This guide aims to assist countries in formulating and implementing monitoring and evaluation strategies.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
It comprises: An overview of the concepts for monitoring and evaluation. The components of the surveillance and response system usually targeted for monitoring and for evaluation, including some practical illustrations on collection and interpretation of data on surveillance attributes. Practical steps in implementing monitoring and evaluation and the identification of relevant indicators. A list of indicators for adaptation at country level.
1.3
Intended users
The guide is designed primarily for the ministry of health staff implementing surveillance and response systems. It is expected to be useful for the following persons: staff of the surveillance and epidemiology units in ministries of health; programme managers at national level; regional and district level surveillance officers; public health laboratory personnel at all levels; other persons with the mandate or interest in monitoring and evaluation of disease surveillance and response systems.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Implementation of surveillance & response systems without routine monitoring will result in little or no adjustment to the plan, thus leading to increased risk of failure, lack of achievement of the desired outcomes and of the overall objectives of the systems. Evaluation of surveillance & response systems serves to: ensure that the surveillance system meets the objectives for which it was formulated; document the status of, and any change in the performance of the system; provide an evidence-base on which to modify surveillance objectives, implementation strategy and planned activities; enable planning of resource allocation; provide explanations for achievements and failures in the system; provide specific recommendations for improving the system.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
2.1
M & E of surveillance & response systems should be guided by the following principles: The surveillance plan should include a detailed M & E plan The sources of information, methods and frequency of data collection and analysis, and use of information should be specified within the M & E plan. Both monitoring and evaluation should have clear objectives which are specific, measurable, action-oriented, realistic, and time-bound (SMART objectives). The availability of baseline data against which changes can be monitored and evaluated should ensured. Monitoring should be routine and continuous while evaluations are less frequent and dictated by need. Monitoring data should be, as far as possible, easily collected through the system itself (with minimal resource implications) and should be collected by persons implementing the system. Monitoring of indicators should be done with equal intensity and frequency in areas where planned changes have not yet been implemented as in areas where the planned changes have occurred. Written records of both monitoring and evaluation should be kept The recommendations resulting from monitoring and evaluation should be acted upon in a timely and appropriate way. The recommendations resulting from monitoring and evaluation should be acted upon in a timely and appropriate way.
2.2
Indicators are variables that can be measured repeatedly (directly or indirectly) over time and provide measures of change in a system. They provide useful information on the status of the system and flag areas that need improvement. They are usually expressed as simple counts, proportions, rates or ratios. These measurements should be interpreted in the broader context, taking into consideration other sources of information (e.g. supervisory reports and special studies), and supplemented with qualitative information.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
2.2.1
A good indicator should have a precise definition of numerator and denominator and should be:
2.2.2
Indicators can be classified in various ways. In the logical framework approach (LFA), there are five types of indicators; input, process, output, outcome and impact indicators. Input indicators are the resources needed to implement the system. They include trained personnel, finance, standards and guidelines, communication facilities, forms for surveillance, computers, stockpiles for emergency response, and any other logistics as deemed necessary. Process indicators are used to monitor and track implementation of the planned activities which are critical for attaining the surveillance core functions such as training, supervision, development of guidelines and tools, etc. Output indicators are measures of the immediate results of the activities. They include reports from surveillance data, feedback given to the data providers, number/proportion of health staff trained, number/proportion of planned supervisory visits implemented etc. Outcome indicators are measures of the quality of the surveillance system and the extent to which the surveillance objectives are achieved. They may include indicators for assessing usefulness of the system, completeness of reporting, use of surveillance data for policy and programme decisions, and appropriateness of outbreak response. Impact indicators are measures of the extent to which the overall objectives of the system are being achieved. They may include changes in case fatality rates from epidemic-prone diseases, changes in morbidity patterns, behaviours changes in health staff in implementing the system, and changes in health-related behaviours of the target population. At the outset of implementation of all surveillance systems, emphasis is placed on the input and process indicators. As the systems stabilizes with time, the emphasis shifts systematically to the outcome, and impact indicators.
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
2.2.3
Selection of indicators
In addition to identifying indicators on the basis of qualities outlined in 2.1.1, the following considerations are useful in their selection: Policy relevance: Can the indicator provide guidance for critical decisions and policy issues? Simplicity: Can the indicator be presented in a clear, concise and easily comprehensible way? Sensitivity: Can the indicator detect a small change in the system? Time-series data: Are time-series data available and reflective of the trend of the indicator over time?
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
These components are illustrated in Figure 2 and provide the basis for the identification of the indicators contained in Annex 3. Figure 2 Components of surveillance and response systems for M & E
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
3.1
Surveillance should be conducted for diseases and conditions considered to be of public health importance. The list of diseases and syndromes in the national health information system (HIS) is useful for planning and routine management but too extensive for effective and useful surveillance in view of the limited human and financial resources. Therefore, depending on the objectives of the system, priority diseases for surveillance should be identified and reviewed regularly to ensure they remain relevant and important. The selection of priority diseases for surveillance, and their periodic review can be achieved through a prioritization exercise conducted at approximately 5-yearly intervals (refer to the WHO Guideline on prioritization of diseases for surveillance). Examples of the indicators that can be used for M & E of priority diseases for surveillance are contained in Annex 3.1.
3.2
The structure of the surveillance and response system is defined by legislation (laws, and regulations, including IHR 2005), the strategy for implementing activities, the implementers and stakeholders, and how they relate to each other and to the various networks and partnerships. The indicators that measure different aspects of the structure of a system constitute part of the evaluation indicators; some useful examples are contained in Annex 3.2.
3.2.1 Legislation1 for surveillance
Public health legislation and regulations, including IHR 2005 (for example, regulations governing notifiable diseases and other communicable diseases of public health importance) provide the regulatory framework for the implementation of surveillance and response systems. Some of these laws and regulations have become outdated and may require some amendments. Periodic review and evaluation will establish the relevance, adequacy and need for update. The IHR 2005 constitute an important component of public health legislation and aim to ensure adequate measures for the protection of public health and strengthening of the global public health response to the international spread of diseases. Their purpose is to ensure maximum security against the international spread of diseases with a minimum interference with the international traffic and trade. Annex 1 of the IHR 2005 stipulates the minimum core capacity requirements for surveillance and response to communicable diseases at the local community level, the intermediate public health response, and also at the national level. They call upon Member States to develop and enhance their capacities for surveillance, reporting, notification, verification, response, and collaboration, and their activities concerning designated airports, ports and ground crossings after an initial assessment. M & E should establish the relevance, effectiveness, progress in implementation and compliance with the legislation.
The definitions and explanations of Legislation, Acts, Regulations and IHR are outlined in the glossary of terminology in Annex 1.
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3.2.2
Surveillance strategy
The surveillance strategy depends on the diseases under surveillance, the objectives of the surveillance system, the methods for conducting surveillance and how the surveillance data are used to inform public health policy and practice. For example, an early warning surveillance system needs to be more comprehensive while a system that serves a programme monitoring function could be conducted through sentinel sites. In a multi-disease surveillance system, a limited degree of integration and coordination may be required for efficiency. Some countries have also embarked on a structured approach to strengthening national surveillance systems through prioritization of diseases for surveillance, systematic assessments of existing systems, development of action plans to strengthen the systems, implementation of these plans, and monitoring and evaluation. M & E of the surveillance strategy should not only establish if the strategy is most suited to meet the surveillance objectives, but should also examine progress and challenges in implementation of the strategy.
3.2.3 Implementers and stakeholders
The important surveillance levels are central, intermediate (province /region, district) peripheral (sub-district, health facility) and community level. Each of these levels may comprise formal and private health-care providers that may or may not be included in the surveillance system. Other stakeholders and implementers include the disease-specific programmes, public health laboratories, and public health training institutions. The roles and responsibilities of the implementers and stakeholders, and how they relate to each other should be clearly articulated. The flow of surveillance data through the system, and the dissemination and utilization of information needs to be clear and known to implementers and stakeholders, and the mechanism for response should be well coordinated across the different levels of surveillance.
3.2.4 Networking and partnership
Surveillance of communicable diseases requires concerted efforts and collaboration between stakeholders and partners in and between countries. At country level, intersectoral collaboration and coordination between key partners is crucial for the implementation of effective and comprehensive surveillance systems. Various surveillance networks and partnerships exist at country level and between countries. The laboratory network is a good example of a country-level network, while collaboration on surveillance and response activities between countries bordering one another represents intercountry networking. Intersectoral collaboration is a necessity in order to implement early warning and response functions. M & E is an opportunity to track network and partnership activities, determine their effectiveness and provide recommendations for improvement.
3.3
The indicators related to the core functions measure the processes and outputs from the system. The core functions include case detection, case registration, case confirmation, reporting, data analysis and interpretation, and public health response including reports and feedback from the 11
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
systems to the data providers, stakeholders and decision-makers. Indicators for M & E of the core functions of surveillance and response systems are given in Annex 3.3.
3.3.1 Case detection
Case detection is the process of identifying cases and outbreaks. Case detection can be through the formal health system, private health systems or community structures. Case definitions and a functioning rumour verification system are vital for case and outbreak detection.
3.3.2 Case registration
Case registration is the process of recording the cases identified. This requires a standardized register to record minimal data elements on targeted diseases and conditions. Monitoring should establish the proportion of health facilities having the standardized registers. Evaluation could then examine the validity and quality of information recorded as well as factors that affect the registration of cases.
3.3.3 Case confirmation
Case/outbreak confirmation refers to the epidemiological and laboratory capacity for confirmation. Capacity for case confirmation is enhanced through improved referral systems, networking and partnerships. This means having the capacity for appropriate specimen collection, packaging and transportation. The existence of internal and external quality control mechanisms are important elements for case confirmation which help to ensure the validity and reliability of test results.
3.3.4 Reporting
Reporting refers to the process by which surveillance data moves through the surveillance system from the point of generation. It also refers to the process of reporting suspected and confirmed outbreaks. Different reporting systems may be in existence depending on the type of data and information being reported, purpose and urgency of relaying the information and where the data/information is being reported. The national guidelines for the different reporting systems should be implemented.
3.3.5 Data analysis and interpretation
Surveillance data should be analysed routinely and the information interpreted for use in public health actions. Appropriate "alert" and "epidemic" threshold values for diseases with epidemic tendencies should be used by the surveillance staff. Capacity for routine data analysis and interpretation should be established and maintained for epidemiological as well as laboratory data.
3.3.6 Epidemic preparedness
Epidemic preparedness refers to the existing level of preparedness for potential epidemics and includes availability of preparedness plans, stockpiling, designation of isolation facilities, setting aside of resources for outbreak response, etc.
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3.3.7
Public health surveillance systems are only useful if they provide data for appropriate public health response and control. For an early warning system, the capacity to respond to detected outbreaks and emerging public health threats needs to be assessed. This can be done following a major outbreak response and containment to document the quality and impact of public health response and control. Surveillance systems designed to monitor and evaluate programme interventions should be evaluated to establish the extent to which the objectives of the systems are being met.
3.3.8 Feedback
Feedback is an important function of all surveillance systems. Appropriate feedback can be maintained through supervisory visits, newsletter and bulletins. It is possible to monitor the provision of feedback by the different levels of surveillance and to evaluate the quality of feedback provided, and the implementation of follow-up actions.
3.4
The support functions are those that facilitate implementation of the core functions and included the following: standards and guidelines (case definitions, laboratory guidelines, outbreak investigation guidelines, etc); training for epidemiology and laboratory personnel and/or community health agents; supervisory activities; communication facilities; resources (human, financial, logistical); monitoring and evaluation coordination.
Standards, norms and guidelines are necessary for implementing, monitoring and evaluating surveillance and response systems. A comprehensive surveillance guideline should define the priority diseases for surveillance and standard and updated case definitions and action thresholds, and include reporting and data management tools, a description of roles and responsibilities and the expected actions by level. Other important guidelines include those for outbreak investigation, for case management and infection control, and laboratory standard operating procedures etc. It is possible to monitor the proportion of surveillance units with updated versions of standards, norms and guidelines, and to review the guidelines for usefulness and ease of applicability.
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3.4.2
Training
Training refers to the needs for capacity building for staff involved with surveillance and response systems through knowledge transfer. Surveillance staff at different levels have varying training needs. An assessment can help to identify the training needs for different categories of staff, which in turn can be used to draw up a training plan. The implementation of the training plan and the proportion of surveillance staff (epidemiology, laboratory and community resource persons) trained on the different aspects of surveillance and response can then be monitored. Evaluation could examine the quality, relevance, impact and cost-effectiveness of the training.
3.4.3 Supervision
Supportive supervision serves numerous functions. It helps to strengthen the capacity of staff and ensure that the right skills are used appropriately, the necessary logistics are in place, and that planned activities are implemented according to schedule. It is necessary for each of the surveillance levels to include supervisory activities in their annual workplans. The proportion of the planned supervisory visits with checklists and feedback reports conducted by different surveillance units during the year can be monitored. Evaluation could then consider the quality and effectiveness of the supervision conducted by staff at the different levels of surveillance.
3.4.4 Communication facilities
In order to support the function of reporting and feedback in any surveillance system, an appropriate and effective medium for communication at each level of surveillance should be defined, instituted and maintained. Evaluation could determine the emerging needs of communication facilities at different levels of surveillance are being met.
3.4.5 Resources
Surveillance and response activities can only be performed if the required and appropriate financial, human and logistic resources are in place. This means identification of the resource needs to implement the various surveillance activities at each level of surveillance during planning stage. These resources should be mobilized from potential sources, managed and used efficiently.
3.4.5 Monitoring and evaluation
M & E is an important element of all surveillance and response systems to ensure that the surveillance objectives are being achieved and that planned activities are on track. A framework and plan for M & E should be developed, indicators identified, and activities implemented. Also ensure that the recommendations resulting from the M & E are disseminated and utilized to improve the systems.
3.4.7 Coordination
It is necessary to ensure effective coordination between implementers and stakeholders for effective and efficient implementation of surveillance and response systems. Through M & E, the needs for improvements in coordination can be identified and effective coordination mechanisms and strategies implemented.
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3.5
Surveillance quality
The quality of the surveillance system is defined by attributes such as completeness, timeliness, usefulness, sensitivity, positive predictive value (PPV), specificity, representativeness, simplicity, flexibility, acceptability, and reliability. While monitoring will help identify changes in the attributes over time, periodic evaluations should assess the extent of the improvements in the quality of surveillance systems, the data they generate, and the type and quality of the public health responses to the information. Surveillance attributes can be evaluated using quantitative and qualitative methods. The updated guidelines for evaluating public health surveillance systems produced by the United States Centers for Disease Control and Prevention (CDC) and the framework for evaluating public health surveillance systems for early detection of outbreaks illustrate some of the approaches. Annex 3b contains indicators related to attributes of surveillance systems.
3.5.1 Completeness
Completeness in surveillance can have varying dimensions and may include the following:
3.5.1.1
completeness of reporting sites/surveillance forms completeness of case reporting completeness of surveillance data
Completeness of reporting sites/surveillance forms
Completeness of reporting sites refers to the proportion of reporting sites that submitted the surveillance report irrespective of the time when the report was submitted. This is measurable in situations where the surveillance system is such that the number of reporting sites or expected surveillance reports is known, as in the case of "zero reporting". Examples include zero reporting of notifiable conditions, weekly or monthly reporting of surveillance data.
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Type of surveillance report being monitored/evaluated: Period of time for monitoring/evaluation: Name of the health jurisdiction/surveillance level:
Information item 1 1. Number of reporting sites in the health jurisdiction (A) 2. Number of reports expected in the time period (B) 3. Total number of reports received within the time period (irrespective of time of receipt) (C) 4. Completeness of reporting sites by quarter (Cr) A1=___
Yearly total
A=___
B1=___
B2=___
B3=___
B4=___
B=___
C1=___
C2=___
C3=___
C4=___
C=___
Cr=(C/B) x 100
The percentage completeness of reporting sites (Cr) = C/B x 100 In a comprehensive system (such as an early warning system for notifiable/epidemic prone diseases) where all reporting sites are expected to report: A = B and B = B1 + B2 + B3 + B4
In a sentinel surveillance system where only a few of the sites are expected to report: B<A
Computing completeness of reporting sites for each of the surveillance reports can: provide a trend analysis on completeness of reporting for each of the surveillance reports over a period of time; help to identify how each site is performing.
Further investigation should provide the reasons for poor and good performances and possible solutions to correct poor performance.
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3.5.1.2
Completeness of case reporting refers to the match between the number of cases reported and the actual number of cases. This can be obtained by comparing the number of the reportable conditions reported to the next higher level over a period of time with the number of cases recorded in the patient register over the same period of time. The capture and recapture method can also be used to estimate the completeness of case reporting. In a system where the level of reporting of detected cases is very high, the completeness of case reporting will be directly related to the sensitivity of the surveillance system.
3.5.1.3 Completeness of surveillance data
Completeness of surveillance data is the match between the expected minimum data requirement and what is reported. The following questions are useful in determining completeness of surveillance data and its implications on public health actions.
3.5.2
Are all the data on each of the required variables in a surveillance form collected, registered and compiled? If not, which are the variables that are not routinely collected and what is the problem in their collection? What is the implication of the missing data on the quality of the surveillance data? How can this problem be resolved?
Timeliness of reporting
The single most important measure of timeliness is whether data are submitted in time to begin investigations and implement control measures. Timeliness of reporting should be measured against standards developed by each country. Important aspects of timelines of reporting in a communicable disease surveillance system include: timeliness of immediate notification, i.e. within 24 hours timeliness of weekly reporting timeliness of monthly reporting
The timeliness of standardized types of reporting can be calculated as indicated in Table 2 below.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Information item 1 1. Number of reporting sites in the health jurisdiction (A) 2. Number of reports expected in the time period (B) 3. Total number of reports received within the time period (irrespective of the time of receipt)(C) 4. Total number of reports received on time within the time period (D) A1=___
Yearly total
A=___
B1=___
B2=___
B3=___
B4=___
B=___
C1=___
C2=___
C3=___
C4=___
C=___
D1=___
D2=___
D3=___
D4=___
D=___
Tr3=(D3/B3) x 100
Tr4=(D4/B3) x 100
Tr=(D/B) x 100
* calculation shown for a "zero" reporting system The timeliness of reporting can be calculated in two different ways depending on the reporting system, as shown below: a) Timeliness of reporting in a "zero" reporting system In a "zero" reporting system where all reporting sites are required to report in a timely manner, irrespective of whether a health event is identified or not, Timeliness of reporting (Tr) = D/B x 100 b) Timeliness of reporting in "non zero" reporting system In a "non zero" reporting system, where reporting is based on cases seen, timeliness of reporting (Tr) is calculated as: Timeliness of reporting (Tr) = D/C x 100 Depending on the reporting system, the proportion of surveillance reports received in a timely manner over a given time frame is computed as indicated above. During an evaluation, factors contributing to timely or delayed reports, and the consequences and implications of the timeliness of reporting should be identified, and appropriate recommendations provided.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
3.5.3
Surveillance data have many potential uses. The usefulness of the surveillance data and the system should be evaluated in the context of the two key surveillance functions i.e. early warning and routine programme monitoring. An early warning system serves to: detect outbreaks of diseases in a timely manner inform appropriate and effective public health responses determine the distribution and spread of disease illustrate the epidemiology of new diseases provide information to categorize the outbreak as of national or international importance provide data to evaluate control measures.
The surveillance systems for monitoring effectiveness of control programmes serve to: estimate disease burden identify risk groups determine incidence trends over time measure outcomes and impacts of preventive and public health interventions evaluate the overall control interventions.
Evaluations should determine the extent to which surveillance objectives are being met. The section below contains examples of how to assess the usefulness of public health data and surveillance systems.
3.5.3.1 Usefulness of surveillance data in an early warning system
As indicated above, surveillance systems with an early warning function mainly serve to provide data that can be used to detect and respond to outbreaks or public health threats in a timely and appropriate manner. To evaluate the actual usefulness of the data for this purpose, the surveillance data in an early warning system over the previous year should be reviewed to identify cases and suspected outbreaks for which an epidemiological response was required. For the suspected outbreaks, it should be determined whether: the suspected outbreaks were detected early by the system epidemiological investigations were undertaken the response was initiated in a timely manner the surveillance data were used to guide the public health response.
In addition, the factors that led to inappropriate or lack of use of surveillance data should be determined. 19
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
3.5.3.2
Evaluators should ask both the surveillance staff and the end users of the data to list the different ways they have been able to use the data, e.g. for case detection, planning, policy, etc. They should also ask them to specify factors relating to lack of use of the data and identify the data elements that are not useful.
3.5.4 Simplicity of the system
Simplicity refers to the structure of the system and the ease of implementation. As part of the structure, the simplicity of information flow from its point of generation to the end users should be considered. The structure for response to ensure that all the different structures are complementary to one another should also be reviewed. In terms of implementing the system, the amount and type of information collected, ease of collection, compilation, analysis, reporting, and ease of using the reporting format should all be considered. Analysing the simplicity of a surveillance system does not easily lend itself to quantitative evaluation, and remains a largely subjective process. The evaluation team can determine the perceived simplicity of the system from the persons responsible for operating and managing the existing system. Some of the suggested questions to be posed include: In your experience/judgment do you believe any part of the surveillance system is unnecessarily complicated? What changes to the system do you believe would make it easier to implement while still achieving its purpose?
Depending on the responses to these initial questions, the evaluators can follow up with more specific questions to determine the features of the system which are identified as problematic, what changes could be made and why the changes might improve the system.
3.5.5 Acceptability of the system
Acceptability of a system is a reflection of the willingness of the surveillance staff to implement the system, and of the end users to accept and use the data generated through the system. Evaluation of the acceptability should establish if the staff implementing the surveillance system, or who otherwise support the system, view it as appropriate to their needs. In cases where the system is found to be inappropriate, suggestions for improvements to make it more acceptable by the implementers and end users of the data should be made.
3.5.6 Flexibility of the surveillance system
Flexibility refers to the ability of the system to be adapted to changing needs such as the removal or inclusion of additional diseases, modification of the reporting frequency, data requirement needs, etc. An early warning system may need to be adapted from time to time to meet additional case detection needs, for example by: adapting the system to the required data collection needs for signals and alerts collecting exposure information and data requirements for outbreak management increasing coverage by increasing data sources or data providers 20
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
modifying the case definitions in use redefining the alert and action threshold values.
The system should also be flexible enough to shift from providing the needs for outbreak detection to outbreak response and control. The following questions could help in ascertaining the flexibility of a surveillance system: Could you please describe how your system was adapted to changes and new challenges? Are there existing elements that make your system difficult to adapt? Briefly describe circumstances when it was not possible to adapt the surveillance system and why it was not possible to adapt it.
Sensitivity in surveillance
3.5.7
Sensitivity in surveillance refers to the proportion of actual cases in a population that are detected and notified through the system. Sensitivity is particularly important in an early warning system designed to detect outbreaks. It is usually not practical to obtain highly accurate estimates of sensitivity as this requires the true number of cases in the population be known, something that is almost impossible, and that the diagnosis of reported cases be confirmed to eliminate false positives. Sensitivity in surveillance can be described at three different levels:
3.5.7.1 Sensitivity of the surveillance case definition
This refers to the ability of the case definition to identify all possible cases in the community. A surveillance case definition is very sensitive but it may create problems by increasing the number of false positives. A laboratory-confirmed case definition may not be very sensitive in countries where laboratory testing is not widely available.
3.5.7.2 Sensitivity of the detection of events for public health response
This refers to the proportion of cases detected and reported through the system. It includes the use of "thresholds" which should trigger intervention.
Sensitivity =
persons with the disease detected by the surveillance system total number of persons with the disease
x 100
3.5.7.3
This refers to the proportion of cases meeting the case definition (regardless of the sensitivity of the case definition itself) that are detected and notified as they should be.
3.5.8 Specificity in surveillance
Specificity refers to the proportion of persons without the disease that are considered by the surveillance system as not having the disease.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Sensitivity =
persons without the disease detected by the surveillance system x 100 total number of persons without the disease
Very low specificity would result in the surveillance system indicating many "false" outbreaks, and the staff spending a lot of resources to verify and investigate.
3.5.9 Positive predictive value
The positive predictive value (PPV) is the proportion of people the surveillance system indicates as having the disease who actually have it. PPV = true positives all positives
The positive predictive value of the case definition (PPVcd) is the proportion of actual cases that meet the case definition (PPVcd). This is calculated as:
PPVcd = cases meeting case definition total number of actual cases
The higher the PPVcd, the better is the case definition. The PPVcd is affected by the sensitivity and the specificity of the case definition, and the prevalence of the condition in the population. Improving the specificity of the case definition would involve making the case definition more restrictive (which may decrease its sensitivity). A low PPVcd means that either the case definition is not adequate or is not applied appropriately. In this case, it may be necessary to review the case definition in use and update or recommend the training of clinical staff in its proper use.
3.5.9.2 The PPV of case detection
The positive predictive value of detecting cases (PPVdc) is the proportion of diseased persons that are detected (clinically or through laboratory confirmation) by the surveillance system.
PPVdc = total cases detected (clinicall y or by laboratory ) total number of diseased persons
The PPV of outbreak detection
x 100
3.5.9.3
The PPVdo of detecting outbreaks refers to the proportion of the alerts detected by the system that were indeed confirmed after initial verification.
PPVdo = total alerts confirmed as outbreaks total alerts received / detected
The higher the PPVo, the better is the surveillance system. If the value of the PPVdo is low then the thresholds used for triggering an alert should be made more specific (higher values) without impairing the sensitivity too much.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
3.5.10
Representativeness refers to the degree to which the reported cases reflect the occurrence and distribution of all the cases in the population under surveillance. Geographical representativeness is particularly important in an early warning system to ensure detection of outbreaks of infectious diseases. In a situation where the reported cases of a particular health condition in a population are not representative of all the cases that are occurring in that population, the disease prevention and health promotion priorities may be inappropriate and inadequate compared to the actual needs. Representativeness can be diminished if: The population attending a given health facility is not representative of the population covered by that facility. Some segment of the population seeks medical care from non-governmental sources that do not report through the formal reporting system. The health facility does not accurately diagnose or report conditions among persons of different ages, sex, origin and background in a standard format. Because the true frequency and distribution of the health condition in a population is usually unknown, it is impossible to measure representativeness accurately. If population-based studies have been conducted and reliable estimates made, then evaluators can compare the frequency and distribution reported by the surveillance system to that established by those studies. The degree to which the reported data corresponds to the data from population-based studies is a measure of the representativeness of the reported data. However, if such population-based data are not available, evaluators must decide whether the importance of knowing the representativeness of the reported data is sufficient to recommend and/or implement one or more of the following: A population-based study of the incidence or prevalence of a particular disease or syndrome. This would provide the most useful data, but is time-consuming and very costly. A study of the demographic characteristics of clinic/health facility attendees and a comparison of this information with that of census data for the same jurisdiction. This is the easiest to do if reliable census data exist. It will not measure representativeness, but it will measure the degree of opportunity for the reported data to be representative. A study to determine the proportion or characteristics of the population that seek medical care from non-governmental facilities. This, combined with follow-up evaluation, will provide information that can be used directly to adjust projections of the occurrence of the health condition in the population. a study of reporting of notifiable conditions by different care providers e.g. nongovernmental, military, private, etc. a study of the diagnostic and reporting practices of the health service. a study on health-seeking behaviour among the public.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
4.1
This plan should be developed at the same time as the plan for implementing and strengthening national surveillance and response systems is being developed. The monitoring plan should include a series of activities that will help to ensure a functioning monitoring system at all levels of surveillance. The planning process should entail: defining components for monitoring defining the objectives for monitoring selecting monitoring indicators identifying methods of data collection for monitoring purposes.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
The workplan for monitoring should comprise: objectives for monitoring indicators for monitoring baseline measurements for each of the indicators frequency of data collection targets methods of data collection levels and persons responsible for collecting the data intervals for analysis and review of the measurements estimated cost to implement monitoring, and budget source. This workplan should be consolidated with the workplan for the evaluation component and incorporated into the overall surveillance and response plan.
4.1.1 Definition of components for monitoring
Section 3 of this guide provides a description of the different components of surveillance systems which can be targeted for M & E. Monitoring of the surveillance system should be accompanied by monitoring of the plan of action (if it exists), as this plan should ensure timely implementation of planned activities, efficient and rational use of available resources in order to achieve the targeted objectives.
4.1.2 Defining the objectives of monitoring
Defining the purpose and the objectives of monitoring ensures that the monitoring activities are useful and are geared towards strengthening the system in question. Monitoring of any surveillance and response system should provide information on: progress in achieving the desired results improvements in the outputs from the system improvements in the attributes of the surveillance system gaps and areas for improvement. Based on the components of the system targeted for monitoring and the established targets, objectives that are specific, measurable, achievable, realistic and time-bound (SMART) should be formulated. These monitoring objectives should relate to specific key result areas (KRAs) or outputs to be achieved through implementation of planned activities of the surveillance and response system.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
4.1.3
Identification of monitoring indicators should be guided by: the rationale, i.e. to track progress towards achieving set targets the frequency of collection of information, i.e. ongoing the method of collection of required data, which should be almost automatic through the system with little or no resource implication.
A model worksheet to aid identification and selection of M & E indicators is shown in Table 3. For each of the monitoring objectives defined above, appropriate indicators (input, process, output, outcome, impact) should be identified to aid monitoring progress towards established targets. If necessary, additional indicators to monitor plan implementation should also be identified. These indicators should be pre-tested for usefulness, clarity, availability of denominator and numerator data, ease of collection and calculation of measurements. Annex 3 contains a list of proposed indicators for adaptation at country level.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
4.1.4
For each indicator, the frequency of data collection, methods for obtaining the data, and frequency of data analysis should be determined. To reduce costs, the collection of monitoring data should integrate into surveillance system e.g. through weekly or monthly reporting. Where it is not possible to collect the data automatically through the system, the additional data collection needs should be integrated as far as possible into routine supervisory visits. Any other additional methods selected should be feasible, realistic and linked to the data sources. Annex 4 describes some methods of data collection.
4.1.5 Development of the monitoring tool
The monitoring tool should aid collection of data and calculation of the measurements on each of the indicators. It should also include a section on the interpretation of the measurements, and the recommendations for overall system improvements. The tool should also contain instructions for use. Annex 5 contains sample tools for collecting data on a few selected indicators. The monitoring tool should be pretested for ease of applicability to ensure that the target users find it user-friendly. Pretest of the tool is achieved through administration of the tool in its final form to a sample of target users to determine whether they understand it and whether it serves the purpose for which it was developed. Any suggestions for modification should be incorporated in the final tool before large-scale production.
4.1.6 Identification of persons to participate in the monitoring system
The monitoring system comprises the implementers and the users of the data. Monitoring should be performed at all levels of the surveillance system by people implementing the system. These people are the primary target users of the monitoring data, but additional users of the data should also be identified. The central level should have the overall coordination of the monitoring activities, and all stakeholders should be involved in planning and implementing the monitoring system.
4.2
4.2.1.
Prepare to monitor
Mobilization of resources
Resources should be mobilized for data collection, compilation, analysis and interpretation. Appropriate logistics for documentation, dissemination and use of information generated should be available.
4.2.2 Preparation of job aids and training of staff
definition of the indicators levels of the surveillance system for data collection when the data should be collected for each indicator
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
o o o o
instruction on how to calculate the indicator value targets for the indicator measurements interpretation of the indicator measurements recommendations for improvements
an analysis tool or form for doing trend analysis for selected indicators any other tool deemed necessary for monitoring the surveillance and response systems.
Health workers should be trained on the use of the job aids, how to collect data on the different indicators, procedures, use of the tools, frequency of collection and how the data should be managed, interpreted and disseminated.
4.2.3 Dissemination of tools and procedures
Job aids, monitoring tools and procedures should be disseminated to all staff involved in monitoring and at each level of surveillance. Continuous availability and maintenance of tools and job aids should be ensured. In case of a computerized monitoring system, the appropriate software and programmes should be installed, and a monitoring database developed.
4.3
4.3.1
The first step in implementing monitoring activities is to generate baseline data on the monitoring indicators against which progress towards established targets can be assessed. The baseline data should be, to a large extent, extracted from the data derived from the assessment of the surveillance and response system. Where some of the data were not captured during the assessment, attempts should be made to collect the additional information. These baseline measurements should be entered and stored in an M & E database.
4.3.2 Collection and analysis of monitoring data
Monitoring data should be collected and compiled according to the schedule set out in the monitoring workplan. It is important to follow up missing data. The data should be validated, cleaned, and analysed at regular intervals and brief summary reports prepared every 36 months.
4.4
Results of monitoring should be disseminated, through the summary reports, to all users of the system and to stakeholders. The results should be used as a basis on which to plan improvements of the surveillance system.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Figure 4
The evaluation cycle
5.1
A comprehensive evaluation should include the surveillance system and the surveillance POA. Evaluation of the surveillance system should: show to what extent the desired outputs and outcomes are achieved; provide explanations for achievements, disparities and failures; document the quality of system and demonstrate any changes in its performance; demonstrate the extent to which the overall surveillance objectives are achieved.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Evaluation of the surveillance plan should: determine the degree to which each element of the plan has been implemented; explain the status of implementation; demonstrate the outcomes and impact of the implemented activities; provide recommendations for improving the POA and its implementation; identify new or previously unrecognized opportunities for improving surveillance implementation.
5.1.2
Where a strategic plan of action (with a defined term) exists for strengthening surveillance systems, it is appropriate to conduct mid-term and end-of-term evaluations. Otherwise surveillance systems should be evaluated every 2, 3 or 5 years. Mid-term evaluations aim at determining whether implementation is broadly on target, whether the objectives are being met or whether some corrective measures need to be instituted. A series of intermediate evaluations may be conducted if required. End-of-term evaluations are conducted at the end of the strategic plan of action to assess the improvements in performance and thus the impact of the plan and of the systems. During the evaluation planning phase, the types and frequency of evaluations to be conducted should be defined. It is important to remember that every evaluation activity has a cost implication and the resources required will need to be identified. Thus planning the types and frequency of evaluation should be realistic and modest.
5.2
5.2.1
The type and scope of the evaluation should be guided by objectives which should be simple, measurable, attainable, realistic, and time-bound (SMART). It is possible to conduct repeated evaluations with similar objectives, or implement a series of evaluations with differing objectives and assessing different components of the surveillance system.
5.2.2 Development of evaluation indicators
Indicators should be identified for each of the evaluation objectives, and should be harmonized as far as possible with the monitoring indicators. The model worksheet in annex 3a can be used to identify and define the evaluation indicators that will help to measure the outcomes and the impact of the system. Annex 3b provides a list of suggested indicators which can be adapted to specific needs.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
5.2.3
Based on these indicators, an evaluation protocol should be developed containing: study design or survey methods (e.g. cross-sectional studies, case studies etc) target population sampling procedures data sources data collection methods (refer to Annex 4 for details) data collection tools (indicators, checklist, questionnaires) plan for data analysis and utilization.
For each evaluation indicator the frequency of data collection and the data collection methods should be defined. Evaluation tools should be pre-tested and adapted as necessary.
5.2.4 Persons to conduct the evaluation
Three main types of evaluation exist: internal/self evaluations external evaluations mixed evaluations.
Internal/self evaluations refer to evaluations initiated and undertaken by implementers of the system, primarily the ministry of health. The involvement of all surveillance levels and stakeholders is encouraged in order to improve the application of the findings to strengthen the system. Evaluations undertaken by persons outside the ministry of health or the actual implementers are referred to as external evaluations. These are useful in identifying issues that the national surveillance programme may find sensitive, and yet need to be pointed out. The disadvantage of external evaluations is that sometimes the recommendations are not used because the implementers of the system do not appreciate the results. To overcome this, the staff should be involved in the conceptualization and consulted at all stages. Furthermore, there should be active discussions with the staff of the major findings, conclusions and recommendations and the final report should be widely disseminated. Evaluation performed jointly by ministry of health surveillance staff (implementers) and partners or external persons is referred to as mixed evaluation. Depending on the scope of the evaluation, its purpose and the available resources, a decision should be made during the planning stage on the type of evaluations to be conducted, and on who should undertake them.
5.2.5 Resource mobilization
Depending on the type of the evaluation, the evaluation team should be constituted, the protocol finalized (objectives, methodology and data collection tools) and the teams trained on its 33
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
application. The necessary financial and logistical resources required for the evaluation exercise should be mobilized and documentation required to support the evaluation exercise should be compiled.
5.3
The evaluation should be undertaken according to the time schedule determined (see above) and data should be collected and compiled according to evaluation protocol. The data should be validated, cleaned, and analysed. A summary report of the evaluation should be prepared, including the background to the evaluation, objectives, methods, results, conclusions and recommendations.
5.4
The evaluation results should be disseminated, through the summary reports, to all implementers and users of the system, to stakeholders, and all who need to know. The recommendations should be used as a basis on which to plan improvements of the surveillance system. Routine monitoring and follow-up evaluations should continue as scheduled.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Bibliography
1. Bishop YNM, Fienberg SE, Holland PW. Estimating size of a closed population. In: Discrete multivariate analysis: theory and practice. Cambridge, MA, MIT Press, 1975. Chapter 6: 229 - 256. 2. CDC. Framework for evaluating public health surveillance systems for early detection of outbreaks; recommendations from the CDC working group. MMWR 2004, 53:No.RR-5. 3. CDC. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001, 50:No.RR-13. 4. International Working Group for Disease Monitoring and Forecasting. Capturerecapture and multiple-record systems estimation I: history and theoretical development. Am J Epidemiol, 1995, 142:10471058. 5. International Working Group for Disease Monitoring and Forecasting. Capturerecapture amd multiple-record systems estimation II: Applications in human diseases. Am J Epidemiol, 1995, 142:10591068. 6. Scott JN McNabb, Stella Chungong, Mike Ryan et al. Conceptual framework of public health surveillance and action and its application in health sector reform. BMC Public Health 2002, 2:2 (http://www.biomedcentral.com/1471-2458/2/2, accessed September 2004) 7. John M. Last, ed. A dictionary of epidemiology, 4th ed. Oxford, Oxford University Press, 2001. 8. Thacker SB. Historical development In: Teutsch SM, Churchhill RE, eds. Principles and practice of public health surveillance, 2nd ed. New York, NY, Oxford University Press, 2000. 9. Wittes JT, Colton T, Sidel VW. Capture-recapture models for assessing the completeness of case ascertainment using multiple information sources. J Chronic disease 1974, 27:2536. 10. Integrated Disease Surveillance in the African region. A Regional Strategy for Communicable Diseases 19992003. World Health Organization Regional Office for Africa, 1999 (AFR/RC48/8). 11. World Health Organization. Revision of the International Health Regulations. WHA56.28 (http://www.who.int/gb/ebwha/pdf_files/WHA56/ea56r28.pdf, accessed October 2005) 12. Protocol for the Assessment of National Communicable Disease Surveillance and Response Systems. Guidelines for Assessment Teams. Geneva, World Health Organization, 2001 (WHO/CDS/ISR/2001.2).
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
produce a given level of effectiveness, or provides the greatest effectiveness for a given level of cost.
Decree: An authoritative order having the force of a law; a legally-binding command or decision entered on the court record. Decree for National Public Health Laboratories: Are the laws, regulations and orders that govern the functions and establishment of public health laboratories in a country. Early warning system: Is a communicable disease surveillance and response system that is designed to detect as early as possible any departure from the usual or normally-observed frequency or phenomenon. Effectiveness*: This is a measure of the extent to which a specific intervention, procedure, regimen, or service, when deployed in the field in routine circumstances, does what it is intended to do for a specific population;1 A measure of the extent to which a health care intervention/activity fulfills its objectives2. Epidemic*: The occurrence in a community or region of cases of an illness, specific healthrelated behaviour, or other health-related events clearly in excess of normal expectancy. The community or region and the period in which the cases occur are specified precisely. The number of cases indicating the presence of an epidemic varies according to the agent, size, and type of population exposed, previous experience or lack of exposure to the disease, and time and place of occurrence. Epidemic threshold: Is the critical number or density of susceptible hosts required for an epidemic to occur. The epidemic threshold is used to confirm the emergence of an epidemic so as to step-up appropriate control measures. Evaluation*: A process that attempts to determine as systematically and objectively as possible, the relevance, effectiveness, and impact of activities in light of the objectives. Several evaluations can be distinguished, e.g. evaluation of structure, process, and outcome. Last, 2001 Flexibility: Ability of the surveillance system to adapt to changing needs, incorporate new diseases, leave out less important diseases, change reporting frequency, change or modify data source. Indicators: Are variables that measure change over time Legislation: Is a legally-enforceable guideline and comprises the principal legislation (acts), and the subordinate or delegated legislation (regulations). International Health Regulations: Are an agreed code of conduct adopted by the World Health Assembly to protect against the spread of serious risks to public health and, the unnecessary or excessive use of restrictions in traffic or trade. Milestones: Key events or markers that show progress in implementation of activities and the related achievements. Monitoring of surveillance systems: Is the ongoing tracking and analysis of routine measurements aimed at detecting changes in the surveillance system.
Cochrane A L. Effectiveness and efficiency; Random reflections on Health Services. London: Nuffield Provicial Hospitals Trust, 1972. 2 Statistical indicators for Planning and Evaluation of Public Health Programmemes; 14th Report of the WHO Expert Committee on Health Statistics. WHO Technical Report Series No. 472. Geneva, 1971.
1
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Notifiable disease*: A disease that, by statutory requirements, must be reported to the public health authority in the pertinent jurisdiction when a diagnosis is made. A disease deemed of sufficient importance to public health to require that its occurrence be reported to health authorities. Outcomes: All possible results that may stem from implementing surveillance and response activities. Output: The immediate result of implementing surveillance and response activities. Positive predictive value of case definition (PPVcd): Ability of the case definition to identify real cases or the proportion of true cases of the disease that meet the case definition. Positive predictive value of detecting outbreaks/ cases (PPVdo): Ability of the surveillance system to detect real alerts, i.e. confirmed alerts (after verification)/all alerts detected. Prioritization: Is the process of identifying and selecting issues or activities using a set of predefined criteria designed for the purpose. Priority diseases: Are diseases/conditions that have been identified to be of important/major public health concern. Quality assurance*: System of procedures, checks, audits and corrective actions to ensure that all testing, sampling, analysis, monitoring and other technical and reporting activities are of the highest achievable quality. Quality control*: The supervision and control of all operations involved in a process usually involving sampling and inspection, in order to detect and correct systematic or excessively random variations in quality. Regulations: Often referred to as delegated legislation or subordinate legislation, are a means of making laws and usually reflect policy objectives. However, they are not made by parliament but rather by someone to whom parliament has delegated the authority to make them. All regulations should be consistent with the authority under which they are made. They can go beyond what an Act provides. Regulations may be viewed as the operational part of the law, commonly dealing with matters such as the meaning of certain terms used in the act; procedures and processes that must be followed or standards that must be met, in order to comply with an act. Reliability*: The degree to which the results obtained by a measurement/procedure can be replicated. Representativeness: Ability of the system to accurately describe the occurrence of a healthrelated event by place and person over time in a given population. Sensitivity in surveillance: The ability of a surveillance or reporting system to detect true health events, i.e. the ratio of the total number of health events detected by the system to the total number of true health events as determined by an independent and more complete means of ascertainment (WHO Protocol for the assessment of national communicable disease surveillance and response systems: Guidelines for the assessment teams). Sensitivity of case definition: Ability of the case definition to detect all cases of the disease targeted for surveillance. Sensitivity of detection of cases: Ability of the surveillance system to detect cases, i.e. proportion of cases notified divided by the total number of cases meeting the case definition.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Sensitivity of the detection of outbreaks: Ability of the surveillance system to detect outbreaks. Situation analysis*: Study of a situation which may require improvement. This begins with a definition of the problem and an assessment or measurement of its extent, severity, causes, and impacts upon the community, and is followed by appraisal of interaction between the system and its environment and evaluations of performance. Specificity in surveillance: A measure of how infrequently a system detects false positive health events, i.e. the number of individuals identified by the system as not being diseased divided by the total number of all persons who do not have the disease. (Protocol for the assessment of national communicable disease surveillance and response systems: Guidelines for the assessment teams) Target*: An inspired outcome that is explicitly stated e.g. to achieve 90% of timeliness of reporting, 100% completeness of reporting, etc. Timeliness of reporting: Proportion of all expected reports in a reporting system received by a given due date. (Protocol for the assessment of national communicable disease surveillance and response systems: Guidelines for the assessment teams) Usefulness: Ability of the surveillance system to meet the objective(s) for which it was designed. Validity: An expression of the degree to which the surveillance data measure the true incidence of cases in the population. Zero reporting*: Reporting of the absence of cases of a disease under surveillance; this ensures that participants have not merely forgotten to report.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Protocol for the assessment of national communicable disease surveillance and response systems
This protocol aids Member States in assessing the status of national surveillance and response systems. It is recommended that the assessment be done at the beginning of implementation of surveillance strengthening activities. The assessment provides information on the strength, weaknesses and opportunities for strengthening the surveillance system, and generates baseline data against which improvements in the system can be measured and evaluated. The results provide the basis for developing strategic plans of action for strengthening communicable disease surveillance and response systems.
WHO guidelines on implementation of early warning and response functions within public health surveillance systems
This guideline is intended to provide Member States with the detailed technical information and understanding to support the establishment of early warning functions within the broader surveillance and response system to meet the minimal core capacity requirements of the International Health Regulations (2005).
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
strategy is to provide a rational basis for decision-making and implementation of public health interventions that are efficacious in responding to national and regional priority communicable diseases. Regional versions of this guideline exist.
Monitoring and evaluation guide for communicable disease surveillance and response systems
Surveillance systems and the surveillance plans of action need continuous adaptation and update. This guide assists countries to monitor the development and evolution of national surveillance and response systems.
Indicator user guide for monitoring and evaluation of communicable disease surveillance and response systems
This guide should be used in consultation with the monitoring and evaluation guide. It provides instructions on the calculation of measurements of the different indicators, their interpretation, and use the measurements to improve the system. It was developed based on the list of indicators contained in Annex 5.3 of the Monitoring and evaluation guide.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Annex 3a Template to guide identification and development of M & E indicators for communicable disease surveillance systems
The table below is a summary of the tables in annex 3b and were developed based on Figure 2. For each component identify the elements for improvement that require monitoring and/or evaluation. Additionally identify appropriate indicators that can be used for M & E. Some indicators are proposed in Annex 3b that can be modified, adapted or changed depending on national priorities and needs. For each indicator identified, decide on how the measurements will be generated and used.
Element Prioritizing public health events for surveillance and response Surveillance legislation (laws and regulations) Compliance with IHR Surveillance strategy and coordination Networking and partnership
Indicator numbers 13 46 79 1019 2026 2730 3134 3545 4648 4952 5357 5863 6466 6772 7379 8081 8283 8487 8889 9094 95
Core functions
Case detection Case registration Case confirmation Reporting Data analysis and interpretation Epidemic preparedness Response and control Feedback
Support functions
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Public health priorities targeted for surveillance Prioritizing public health events for surveillance and response
Indicator definition Type & purpose1 of indicator Input/ process E Value Surveillance Frequency of level data collection National Every 510 years or as necessary Data source Method Category of indicator2 O
Objectives Existence of for disease objectives for surveillance surveillance of diseases in the national communicable disease surveillance system Disease Evidence of prioritization prioritization of diseases for surveillance Updated list of diseases under surveillance Number of years since last update of the list of diseases under surveillance
Y/N/U
Y/N/U
National
,,
National
,,
Component: Element:
No Indicator
Input Requirement for E update or amendment of legislation (laws and regulations) for communicable disease surveillance and response activities Rating of the level Process M&E of compliance with the surveillance legislation (laws & regulations) Existence of a decree for NPHL Input E
Y/N/U
1, 2, 3, 4, 51
Every 25 years
KIs
KI interview
Y/N/U
National
Every 25 years
2 Categorization
The purpose of the indicator is either for monitoring (M), for evaluation (E) or for both M & E. of indicators: C = Core indicator O = Optional indicator Y, yes; N, no; U, unknown; KI, key informant.
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
Y/N/U
KI
KI interview
Input E
Y/N/U
National
25 years
KI
C KI interview, observation
Output M&E
Percent
National
Annually
Review of C document s
Component: Element:
No Indicator
10
Assessment of the Process E national surveillance systems for communicable diseases performed Input Presence of a E strategic and operational plans for implementing and strengthening communicable disease surveillance and response systems Process M&E
Y/N/U
11
Y/N/U
National
12
Percent
Annually
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
13
Monitoring system for communica ble disease surveillance and response systems
Percent
Monitoring reports
14
Performance Whether evaluations are of routine conducted evaluation according to plan Presence of a surveillance coordinating body Presence of a surveillance unit at national level for coordination of communicable disease surveillance activities Proportion of scheduled surveillance (IDSR) coordination meetings held
Process M&E
Y/N/U
National / state
25 years
Evaluation reports
15
Input E
Y/N/U
National
Every 5 years
16
Process M&E
Percent
National
Annually
Minutes of meetings
Review of C minutes
17
Laboratory representation in the surveillance coordinating body Existence of documented roles & responsibilities
Process Regular coordination body E includes laboratory personnel Roles and responsibilities are welldocumented at each level of surveillance system Input E
Y/N/U
National, sub-national
Annually
Meeting reports, KI
18
Y/N/U
Every 5 years
19
Process Evidence of Evidence of E sharing of sharing of resources/activitie resources s between different surveillance programmes
Y/N/U
Annually
KI interview
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
20
Process Existence of E intersectoral collaboration, networking and partnerships with other sectors (water and sanitation, agriculture, animal health, etc) Existence of functional laboratory networks established Process E
Y/N/U
21
Y/N/U
National
22
Cross-border Evidence of a collaboration framework for intercountry/cross -border collaboration Proportion of Planned cross border planned crossborder meetings meetings held Evidence of Regular intercountry regular intercountry meetings meetings Routine informationsharing between neighboring countries Evidence of routine sharing of data and information between neighboring countries, in regional and international networks Existence of intercountry and cross-border communications during outbreaks
Input E
Y/N/U
National
Report of cross- Review of relevant border reports, meetings interview of personnel Minutes of meetings, workplans, KI
23
Process M&E
Percent
National, district
Annually
24
Process M&E
Y/N/U
National
25
Process M&E
Y/N/U
National
Annually
26
Process E
Y/N/U
National
Annually
KI interview
48
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
27
Input Proportion of M&E health facilities with standard case definitions for diseases to be reported regularly in the surveillance system (epidemicprone, vaccinepreventable & other diseases of public health importance) Existence of surveillance systems for the detection of healthcareassociated infections and outbreaks in hospital settings Process M&E
Percentage
Observation C
28
Y/N/U
National
Annually
29
Process Existence of Existence of a E event based mechanism to surveillance capture unusual or public health events from nonroutine sources in the health system (e.g. from the community, media or other informal sources) Capacity to detect and notify unusual/ abnormal health events Inclusion of unusual/abnormal health events in the surveillance system for immediate reporting Process E
Y/N/U
KI
KI interview
30
Y/N/U
49
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
31
Availability of registers
Percentage
Health facility
Observation
32
Process M&E
Percentage
District, national
Annually
Review of C registers
33
Process M&E
Y/N/U
National
Annually
Review of O documents
34
Input/process Existence of Existence of E rumour log rumour log or database for registration of suspected public health events from informal sources
Y/N/U
Observation
Component: Element:
No Indicator
35
Y/N/U
C KI interview, observation
36
Input/process Y/N/U Presence of a documented list of E reference laboratories for confirmation of epidemic-prone diseases Input Capacity for timely referral of M & E samples to reference labs for rapid confirmation of causative agents Routine testing and reporting of antimicrobial resistance Process M&E Y/N/U
Annually
KI
C KI interview, observation
37
Annually
KI interview
38
Y/N/U
National
Annually
50
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
39
Routine monitoring of food safety Routine monitoring of water quality Knowledge of where to refer samples appropriately
Y/N/U
KI, record of food safety results KI, record of water quality results KI
40
Process M&E
Y/N/U
National, sub-national
Annually
41
Input Presence of a documented list of E reference laboratories for confirmation of epidemic-prone diseases Presence and maintenance of appropriate laboratory diagnostic reagents Presence and maintenance of supplies for specimen collection and transportation Input M&E
Y/N/U
Annually
C KI interview, observation
42
Laboratory reagents
Y/N/U
National, sub-national
Annually
KI, reagents
KI interview, observatio n
43
Input M&E
Y/N/U
National, sub-national
Annually
KI, supplies
KI interview, observatio n
44
Proportion of Laboratory confirmation outbreaks that are of outbreaks laboratoryconfirmed Presence of quality assurance system Performance of routine external quality assurance
Output M&E
Percentage
Annually
45
Process E
Y/N/U
51
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
46
Process Proportion of M&E cases of diseases targeted for elimination/eradic ation1 line listed or reported using case-based reporting forms in the past 12 months
Percentage
Document review
47
Output Proportion of Timely notification epidemics (above M & E of epidemics epidemic threshold ) detected in previous 12 months that were notified to the next higher level within 2 days of detection Reporting of healthcareassociated infections/ outbreaks in hospitals Proportion of hospitals that routinely report outbreaks occurring within the health-care setting Process M&E
Percentage
Annually
Outbreak log
Review of log
48
Percentage
National, district
Annually
52
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
49
Output Proportion of M&E health facilities with evidence of data analysis by time, place and person for selected indicator diseases (epidemic-prone, vaccinepreventable, others of public health importance) Input Presence of preE defined action thresholds for selected indicator diseases (epidemic-prone, vaccinepreventable, others of public health importance) Input Proportion of surveillance units M & E with defined epidemic threshold values for priority diseases Evidence of routine laboratory data analysis and interpretation Output M&E
Percentage
50
Y/N/U
National, sub-national
Annually
Guidelines, KI
O KI interview, observation
51
Percentage
National, sub-national
Annually
National, subnational
C KI interview, observation
52
Y/N/U
53
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
53
Input Presence of E epidemic preparedness plans Existence of funds for emergency response Input M&E
Y/N/U
ObservaC tion/review KI interview, budget review (disaster/ epidemic preparedness plans, diseasespecific plans) KI interview, document review C
54
Y/N/U
Annually
55
Adequacy/ availability of supplies and drugs for outbreak management and control
Output Proportion of public health units M & E that experienced shortage of drugs and supplies for the most recent outbreak (define the time frame e.g. 3, 6, 12 months)
Percentage
National, sub-national
Quarterly, annually
56
Availability of contingency stocks Availability of IEC materials for surveillance and response
Input/process PercentProportion of age surveillance units M & E that have contingency stocks for 36 months Input Proportion of surveillance units M & E with IEC materials/activities Percentage
National, sub-national
Quarterly, annually
KI, stock cards, logistic management record Existing IEC strategy & materials
57
National, sub-national
Annually
54
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
58
Y/N/U
Review of minutes, KI interview KI interview, reports of outbreak investigations KI interview Review of documents
59
Input E
Y/N/U
National
Annually
KI
60
Districts with RRTs Capacity for outbreak response Availability of rapid response kits
Proportion of districts with RRTs Proportion of outbreaks responded to in the previous 12 months1 Availability of rapid response/ emergency kits at various levels
Percentage Percentage
Annually
KI
61
Annually
62
Input M&E
Y/N/U
National, sub-national
Annually
KI
63
Input M&E
Percentage
National
Annually
KI
Component: Element:
No Indicator
64
Existence of Presence of a feedback regular mechanism feedback Feedback disseminated Feedback received Proportion of feedback reports/bulletins disseminated Proportion of feedback bulletins/reports received from the next higher level
Y/N/U
Annually
65
Output M&E
Percentage
National, sub-national
Annually
66
Output M&E
Percentage
National, sub-national
Annually
Outbreak investigation includes preliminary timely measures leading to confirmation of the outbreak and institution of appropriate measures.
55
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
67
Surveillance standards and guidelines Surveillance units with standards and guidelines Standard case management protocols
Y/N/U
68
Input M&E
Percentage
National, sub-national
Annually
C KI interview, observation
69
Input E
Percentage
National, sub-national
Annually
Health units
C KI interview, observation
70
Process M&E
Percentage
Sub-national
Annually
Health units
Observation C
71
Input M&E
Percentage
National, Sub-national
Annually
Observation C
72
Input
Percentage
6-monthly
KI
C KI interview, observation
Please check for weekly and monthly reporting forms for communicable diseases.
56
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
73
Availability of training manuals/ modules for surveillance Availability of surveillance training plan Staff trained on surveillance/IDSR
Percentage
Surveillance units
O KI interview, observation
74
Input E
Percentage
National, sub-national
Annually
Training plans
Observatio n
75
Input M&E
Percentage
National, sub-national
Annually
76
Laboratory personnel trained on innovative techniques HCWs trained in infection control Districts having trained epidemiologist Staff receiving refresher courses on surveillance
Input M&E
Percentage
National, sub-national
Annually
77
Input M&E
Percentage
National, sub-national
Annually
78
Input M&E
Percentage
National
Annually
KI
79
Process M&E
Percentage
National, sub-national
12 years
57
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
80
Percentage
81
Proportion of Input surveillance units with functional communication facilities for immediate, weekly, and monthly reporting1
Percentage
National, sub-national
Annually
Component: Element:
No Indicator
Input Evidence of a budget line for surveillance activities (reporting forms, feedback bulletins, communication, supervision, training, etc) Proportion of surveillance units with functional computers for surveillance purposes Input
Y/N/U
Percentage
National, sub-national
Annually
KI
KI interview, observation
1 The
communication facilities should be appropriate to the surveillance level and may include one or more of the following; email, fax, telephone, radio call. 2 To be asked at national and any other level as deemed appropriate.
58
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
84
Percentage
Review of documents
85
Output Proportion of M&E expected surveillance reports (weekly or monthly) received on time Output Proportion of M&E outbreaks (with observed no. of cases > threshold values) notified to the next higher level within 48 h of detection Proportion of suspected outbreaks that were verified within 48 h of detection Output M&E
Percentage
National, sub-national
Annually, quarterly
Review of documents
86
Percentage
National, sub-national
6-monthly
Review of documents
87
Percentage
National, sub-national
6-monthly
Review of documents
To effectively monitor timeliness, the different surveillance units may be required to keep a chart that shows the submission and receipt dates of the different surveillance reports. Timeliness should then be judged against the standards set by the ministries of health. Evaluation will provide explanations for achievements and discrepancies observed.
59
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
88
Completeness of reporting
Proportion of total Output M&E expected surveillance reports received, regardless of the timeliness of submission Proportion of surveillance reports/registers with no missing required information1 Output E
Percentage
Reports
Review of reports
89
Percentage
National, sub-national
Annually
Reports
Review of reports
Component: Element:
No Indicator
90
Scale 152
KI,
KI interview
91
Output Rating of the simplicity of the surveillance system (in terms of data collection, compilation, reporting, analysis and utilization) by implementers and users of the systems Output Rating of the ability of the surveillance system to adapt to changing needs, as perceived by the national health managers and evaluators
Scale 15
National, sub-national
2-yearly
KI
KI interview
92
Scale 15
National, sub-national
510-yearly
KI
KI interview
This indicator is applicable in systems emphasizing zero reporting and does not need to be monitored on a routine basis. 2 1 = 20 %; 2 = 40%; 3 = 60%; 4 = 80%; 5 = 100%
1
60
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Component: Element:
No Indicator
93
Scale 15
KI, databases
94
Output Rating of the acceptability of the surveillance system by users and implementers
Scale 15
National, sub-national
25-yearly
KI
Component: Element:
No Indicator
95
Output Rating of the reliability of the surveillance data/ reports by implementers and users of the system
Scale 15
KI
KI interview
61
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
In situations where there has been a prior assessment of the surveillance and response systems, it is preferable that the same methods used for the assessment are re-applied for the evaluation exercise, but with the necessary modifications to take account of the evaluation objectives. Ongoing monitoring and repeated evaluations produce trends over time and can also allow comparison of the results generated. Whatever specific methods are used, it is important to have components of field or on-site verification of the information gathered and to observe the actual facts on the ground.
4.1
Potential sources of data for routine monitoring and periodic evaluation include:
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
laboratory registers/records food and water quality test results weekly, monthly, quarterly, half yearly and annual surveillance reports self-assessment reports (where they exist) outbreak or rumour log surveillance bulletins case reports outbreak investigation and response reports minutes of surveillance coordination meetings (e.g. the IDSR monthly coordination meetings) surveillance plan of action previous monitoring and evaluation data and reports surveillance staff and stakeholders.
4.2
Both quantitative and qualitative methods of data collection may be used to generate monitoring and/or evaluation information. In deciding on the best method for collecting the required data, the practical implications of data collection, data management, processing and utilization to improve the system should all be considered. An information need or indicator may have several different possible sources and methods for collection. Each of the methods has specific advantages and disadvantages in terms of costs, reliability of data, required skills, ability to quantify results, richness and adequacy of the information generated. Overall, selection of the methods should take into consideration the category and level of training of staff who will be involved in collecting, compiling and analysing the information.
4.2.1 Checklist for feasibility of data collection methods
The checklist below can be used in the design stage as an aid to assess the appropriateness of the different methods of information gathering: Feasibility: will it be possible and practical to collect the required data or information using the suggested methods? Validity: will the methods generate valid information? Reliability: will the method produce reliable data? Sensitivity: is the method sensitive enough to detect even the smallest change? Costeffectiveness: is it the most cost-effective method or are there other methods that can produce similar results but at a lower cost? Timeliness: will the method generate the required information in time for appropriate action? This is relevant for the monitoring, which is an ongoing process. 63
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
4.3
Whichever data collection methods are used, they should be guided by standardized questions or indicators. Examples of these are given below. Activities: which of the planned activities have actually been implemented, and of the implemented activities, which ones were implemented as per schedule? Outputs: how many of the planned targets have been achieved? (e.g. proportion of health staff trained in surveillance, proportion of health facilities that received case definitions, etc). Outcomes: What has been achieved as a result of the outputs? (e.g. as a result of training or provision of surveillance reporting forms or communication facilities, timeliness and completeness of reporting improved from 50 80%, which also improved timeliness of outbreak response, etc). Impacts: what has been achieved as a result of the outcomes or what contribution is being made to the overall goal? Are there negative or positive anticipated impacts? (e.g. reduction in disease-specific case fatality rates; achieving or failing to achieve elimination goals, etc). Lessons: what has been learnt to contribute to the pool of information on surveillance or to help improve implementation of surveillance activities? (e.g. in Uganda, publishing the weekly surveillance data in the Government newspaper that is read by the majority of the population increased timeliness and completeness of weekly reporting from 60% to over 90% within a period of 6 months).
4.4
Some of the quantitative methods that are useful to derive monitoring and evaluation data include:
4.4.1
questionnaires and surveys case studies e.g. impact evaluation case studies direct observations routine and periodic analysis of routinely-collected data.
Questionnaires and surveys
Questionnaires and surveys are important and the most commonly-used methods for evaluations. However, because it is not feasible and cost effective to study all the sample units in a surveillance system, the use of sampling methods that result in a representative sample is recommended. This will normally include multistage sampling as there are many different levels of surveillance. Within each level, selection of the study sites and subjects can be made by the simple random technique (SRT). Purposeful selection may be applied in special circumstances or when there are characteristics that may be useful to study in order to re-apply some of the lessons. 64
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
The following criteria are useful in the selection of the study sites and study units: geographical representation of the study sites presence of regional or higher level laboratories ease of accessibility to the study areas inclusion of good and poor performing areas/facilities presence of public health training institutions (depending on what is being evaluated).
A combination of different methods for information gathering can be applied and often include interviews, observations, review of records and analysis of routinely-collected information, review of activity reports or other related surveillance reports, review of previous monitoring and evaluation reports. Surveys are one of the most expensive methods of evaluation of national surveillance systems and are normally recommended for specialized and highly focused evaluations such as the midterm and end-of-term evaluation of surveillance systems. Repeated surveys can provide information for monitoring performance and progress of a surveillance system. They should, where possible, be done using a standardized tool and in similar geographical location.
4.4.2 Case studies
Case studies are sometimes used for evaluations as they allow for focused data collection about specific performance questions or indicators from a sample of study units. Case studies usually provide an in-depth understanding of the issues being studied or documented. However, they are normally considered unrepresentative and should be used in combination with other methods. Case studies are particularly useful for evaluation purposes e.g. impact evaluation. Special case studies are useful in documenting new strategies and achievements, or providing explanations for factors underlying successes and failures in the surveillance system. They can also be used for comparing poorly- and well-performing provinces, districts and health facilities.
4.4.3 Direct observation
Direct observation is useful for both monitoring and evaluation. It is usually used in combination with other methods. It provides actual evidence of the indicator or variable being studied. For example, the presence of case definitions, evidence of their use, or evidence of data analysis (by observing displayed charts, graphs, tables or maps) can be observed directly.
4.4.4 Periodic analysis of routinely-collected data
Minimum health data that include age, sex, geographical location, diagnosis and reporting facility are routinely collected and compiled at the health facility level, mainly for planning purposes and for reporting to the next higher level. Such information can be obtained from sources such as the health registers, case report forms, notification reports, other relevant information from sentinel sites, etc. Often such data are compiled for onward transmission or for purposes of preparing end-of-year reports and no attempts are made to interpret the information analysed. Such sources can provide useful information on progress of activities and on the evolution of the system if analysed routinely.
65
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Such data will usually provide information on outcome indicators such as completeness and timeliness of reporting, and impact indicators that may be reflected in the trends of the different diseases under surveillance. It is important to identify the kind of information or indicators derived from routine data sources that can be useful in monitoring or evaluating the system. For such information to be useful it is often necessary to triangulate it with information from other sources such as activity reports, outbreak investigation and control reports, health intervention reports (e.g. mass vaccination campaigns, health education, etc) or actual evaluation surveys. This method is particularly useful for monitoring purposes especially if the indicators for routine monitoring are identified and organized into a monitoring tool that can be filled in by staff at regular intervals.
4.4.5 Review and analysis of hospital discharge records
This method has been used to evaluate the sensitivity of surveillance systems. A sample of hospitals should be selected and hospital discharge records reviewed for cases that should have been reported. This requires a mechanism to verify the cases that had been reported through the surveillance system. This verification is usually impossible for highly aggregated systems, but can be done for most the serious diseases or rare conditions such as those targeted for elimination or eradication.
4.4.6 Capture and recapture method
The capture and recapture method is useful for the evaluation of sensitivity of surveillance systems. In this method, additional sources of information about cases (e.g. social security claims, laboratory registers, etc) are identified and the proportions of cases appearing in the other systems, and separately in each system are assessed. This gives a very good estimate of sensitivity and can be repeated over time to track progress.
4.5
Qualitative methods that can be used to aid monitoring and/or evaluation of national surveillance systems include:
4.5.1
supervision surveillance meetings and workshops document review focus group discussions (FGD) key informant interviews (KI) analysis of strengths, weaknesses, opportunities and threats (SWOT analysis).
Supervision
Supervision occurs in the context of the hierarchy. It is the process by which the lower level health staff are supported and guided by the higher level(s) to help them perform better, and to ensure that planned activities are broadly on target. Supervision of the surveillance staff at the different levels of surveillance provides opportunities for informal training, support and qualitative monitoring. The lower the surveillance level, the more rigorous is the required 66
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
supervision. Each country needs to prepare a supervisory plan that meets the needs of the different levels of surveillance. A standardized tool which details the process and the areas for supervision should be provided to each level. Supervision of national surveillance activities can be integrated into the overall supervisory activities of health-care delivery systems or it can be more focused and performed separately. It is necessary to have a standardized supervisory checklist that is easy to use and apply at the different levels of surveillance. This checklist should include process (activities to be implemented), output, outcome and some impact indicators. The measurement of the indicators in the checklist provides a good source of monitoring data in particular, and is also useful for evaluation purposes. During the supervision, attempts should be made to obtain explanations for both failures and successes, and to discuss with the surveillance level staff the best way to overcome the challenges and constraints, so that they feel part of the whole exercise and can then implement the recommendations. The completed supervisory checklist should normally contain a section summarizing major findings, recommendations for follow-up during the next supervisory visit and should be signed by both the supervisors and the supervised. This summary section should be produced in duplicate, a copy taken by the supervisor and the other copy retained at the level of supervision for reference purposes during follow-up supervisions. If planned appropriately and if the indicators for monitoring are integrated within the supervisory checklist, supervision can be a very cost-effective means of generating data for routine monitoring. The pre-selected indicators for monitoring the performance of the surveillance system can be fed into an M & E database, analysed, and the results interpreted and used for further improvements in the system. Supervision, if it is done properly and written records kept, can also be very useful in monitoring implementation of the plan of action and of the overall surveillance system.
4.5.2 Surveillance meetings and workshops
Meetings normally provide useful qualitative information which is often difficult to verify and thus they are usually not considered as practical methods for deriving data on monitoring indicators for surveillance. However, repeated and focused meetings, with clear objectives can sometimes be used to report and discuss data on the selected indicators which pertain to the performance of the surveillance system. In this case, the meeting agenda should include the surveillance indicators of interest e.g. reporting on progress of implementation of the surveillance workplan. The monthly surveillance coordination meeting recommended in the IDSR strategy is one such meeting through which monitoring of surveillance activities can be achieved. On the other hand, special meetings, for example in form of a workshop, can be organized whereby the different levels of surveillance report on progress in implementing the overall surveillance system. For such meetings to be useful for M & E purposes, standardized tools which reflect the progress of implementation of activities and their outcomes should be provided to the different surveillance levels as a guide for reporting, and the outcome should be documented through reports.
67
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
4.5.3
Document review
Review of relevant documents can supplement other data collection methods and the information from all different sources can then be merged and synthesized to make a conclusion. Usually, the indicator or variable including the data source is pre-defined and the relevant documents are reviewed for the measurements of these indicators/variables. The information collected is compiled and analysed either manually or by use of appropriate computer software. Conclusion regarding the performance of the indicator or variable being studied can be derived based on the results of the triangulation of data from all the available sources reviewed.
4.5.4 Focus group discussions
FGDs are particularly useful for collecting qualitative information. A small number of experts or implementers of the system should be identified who are well-versed in the topic area for discussion, and who represent the viewpoints of all concerned. These people are brought together for a meeting (of about 90 min) which should be guided by questions organized around broad sub-themes to help focus the discussion. At least 46 FGDs should be organized around the same broad themes but with different participants. The information generated should be transcribed and analysed.
4.5.5 Key informant interviews
Key informants (KIs) represent a group of people, who, by the nature of their job, have expert knowledge on the performance of the surveillance system. Depending on the variables of interest, KIs are people such as the head of the epidemiological surveillance unit, programme managers, district directors of health services, etc. The KIs can be interviewed with the aid of a standardized key informant guide or questionnaire. The information generated is often analysed in order to outline strengths, weaknesses, opportunities and threats and should be used to draw conclusions and provide recommendations to improve the system.
68
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
69
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
70
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Proportion of surveillance reports sent to the next higher level in a timely manner
Measurement: Timely reporting Proportion of surveillance reports sent to the next higher level on time Surveillance reporting level: Surveillance officer: Health facility: Health subdistrict: District:
Province:
Surveillance Date report Surveillance Date report Surveillance Date report Surveillance Date report week sent to next week sent to next week sent to next week sent to next level level level level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
71
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Surveillance week 2nd quarter reports: On time, or no. of days late: 8+ 7 6 5 4 3 2 1 On time 14 15 16 17 18 19 20 21 22 23 24 25 26
Surveillance week
72
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Surveillance week 4th quarter reports: On time, or no. of days late: 8+ 7 6 5 4 3 2 1 On time 40 41 42 43 44 45 46 47 48 49 50 51 52
Surveillance week
73
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Proportion of surveillance reports received in a timely manner at the next higher level
Proportion of surveillance reports received timely at the next higher level Name and level of surveillance unit receiving report Surveillance report Total no. of surveillance reports expected = Health sub-district District Province National
Weekly reporting
Monthly reporting
Surveillance week
1 2 3 4 5 6 7 8 9 10 11 12 13 14 .. .. .. .. .. .. .. .. .. .. .. 52
Reporting Unit
74
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Proportion of cases of diseases for case-based reporting that were reported to the district using case-based report forms
Proportion of cases of each disease for case based reporting that were reported to the district using case-based reporting forms Name of disease for case-based reporting (diseases targeted for elimination and eradication1) Name of health facility: District: Surveillance officer: Report number Targeted disease reported Date report received at District The original report Date of follow-up was on correct contact with the case-based source of report2 form?(Y/N) Date that correct form was received Province:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 .. ..
1 2
The log can be used to record all reports of all targeted diseases If the case-based form was not used to report the case, additional information from reporting surveillance officer may probably be needed. Plans should then be made for more extensive follow up and response
75
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Proportion of surveillance units that have current trend analysis for selected indicator diseases
Measurement: Data analysis
Surveillance units with current trend analysis for selected indicator diseases Surveillance unit: Surveillance supervisor: Health facility: Health subdistrict: District: Province: National:
Indicator diseases
Surveillance level, date of visit and those not having a current trend line SU 1 SU 2 SU 3 SU 4 SU 5 SU 6
SU2:
SU3:
SU4:
76
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Proportion of suspected outbreaks notified to the next higher level within two days of surpassing the epidemic threshold
Measurement: Outbreak response
Proportion of suspected outbreaks of epidemic-prone diseases notified to the next higher level within two days of surpassing the epidemic threshold
Surveillance Unit:
Health facility:
Health subdistrict:
District:
Province:
Surveillance officer:
Disease reported
77
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
District: Surveillance officer: Outbreak report number Source of outbreak report Disease
Province:
Date investi- Case data have been summarized by at gation began least one variable in each of the three groups (write the names of the variables used in the appropriate column ) TIME (e.g. by date of onset of illness) PLACE (e.g. PERSON by place of (e.g. by ageresidence) group)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
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Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Province:
Date initial Date outbreak report confirmed by received at laboratory district level
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
79
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
Province:
Location of outbreak
Control measures Enter the Were start and end appropriate dates control interventions implemented to all the identified populations at risk? (Y/N) Date incidence of the disease returned to pre- outbreak levels Date in col.7 was consistent with timely implementation of control measures? (Y/N)
80
Communicable disease surveillance and response systems. Guide to monitoring and evaluating
81