INTRODUCTION TO SURVEILLANCE

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 Questions

• What do you think of when you hear the

word “surveillance”?

• What do you suppose is the definition of

surveillance when applied to infection
prevention and control?
 Learning Objectives
• Define surveillance and its role in an infection
prevention and control program

• Describe types of surveillance and

advantages and disadvantages of various
surveillance strategies

• Give examples of basic measures of disease

frequency and describe applications
 Public Health Surveillance Definition

The ongoing, systematic collection, analysis, and

interpretation of health-related data essential to
the planning, implementation, and evaluation of
public health practice, closely integrated with
the timely dissemination of these data to those
responsible for prevention and control
 Surveillance in the Healthcare Setting

Surveillance of healthcare—acquired infections (HAI)

is the foundation for organizing, implementing, and
maintaining an effective infection prevention and
control (IPC) program in the health care facility

“If you don’t measure it, you cannot improve it”

~ Lord Kelvin
 Considerations for Surveillance

 Frequency
 Severity
 Cost
 Preventability
 Communicability
 Methodologic Issues

Goals
Causal pathway
Information needs
Data sources, methods
Case definition
Evaluation: Balance of attributes
Interpretation of data
 Interpretation of Data
Issues to Consider

Source of data
Reliability of diagnosis
Potential biases in detection/diagnosis
Definition of a case
Completeness of data
Reporting bias
Consistency in data collection
Completeness
Context
 Surveillance in the Healthcare Setting:
Objectives

Establish endemic or baseline rate of infections

Compare HAI rates within/between health care facilities
Engage clinical team to adopt best practices
 Introduce evidence-based and cost-effective
interventions to reduce HAI
Identify and control outbreaks
Evaluate success of the ICP interventions
Identify priority areas to allocate resources

Ultimate aim is to reduce HAI

Components of a Strong Surveillance Program

Systematic
Ongoing
Data Collection
Analysis
Interpretation
Dissemination
Action
 Surveillance in the Healthcare Setting

Data must be
 Collected
 Validated
 Analyzed
 Interpreted
 Disseminated in a timely manner

Collecting and recording data is useless if no further

action is taken
 Surveillance is synonymous with the premise of “information for
action”
 Surveillance in the Healthcare Setting:
Methods

When applicable, data set should include:

Information on the infected patient or resident
Information on medical treatment or procedures at the
time of infection
Any underlying medical risk factors of the patient

Information on both numerator and denominator data

should be collected for the calculation of rates of infection
 Surveillance in the Healthcare Setting:
Methods

Flexible to address challenges

 Technological changes within the health care facility
 Short lengths of stay
 Healthcare worker shortage and turnover
 Increased frequency of invasive procedures or devices
 Post-discharge surveillance, as appropriate
Characteristics of a Strong Surveillance Program

Targets
 Infection prevention
 Performance improvement
 Patient safety
 Public health activities

Engages in mandatory and public reporting

Characteristics of a Strong Surveillance Program

Able to identify risk factors for infection

 Adverse events
 Outbreaks
 Emerging infectious diseases
 Antibiotic-resistant organisms
 Bioterrorist events

 Implements control or risk-reduction measures

Monitors the effectiveness of intervention

 Various Methods of Surveillance Used in Infection
Control
Methods Source of Data Comments
Continuing surveillance of all Medical, nursing, laboratory Time-consuming and not
patients (Prospective, active records cost-effective. Infection rates
surveillance) are low in some specialties.
Ward liaison Twice-weekly visits to wards Less comprehensive than
continuing surveillance, with
Discuss all patients with staff similar disadvantages.
and review records
Laboratory-based Laboratory records only Depends on samples taken
and information on request
form.
Laboratory-based ward Reporting of laboratory Early detection of outbreaks
surveillance/selected records and outbreaks by and incidence in studies in
continuing surveillance ward staff and continuing selected areas of infection.
surveillance in special units or
infections

Adapted from: Glenister HM, Taylor LJ, Bartlett CLR, et al. An evaluation of surveillance methods for detecting infections in hospital inpatients.
Journal of Hospital Infection 1993; 23:229-42.
 Various Methods of Surveillance Used in Infection
Control
Strategy Pros
Incidence Provides data on infections
due to all organisms, on all
infection sites, and on all units
Identifies clusters
Establishes baseline infection
rates
Allows outbreaks to be
recognized early
Identifies risk factors
Prevalence Inexpensive
Efficient use of time; can be
done periodically
Cons
Expensive and labor intensive
Large amounts of data
collected with little time for a
analysis
No defined prevention
objectives
Difficult to develop
interventions
Not all infections are
preventable
Over-/underestimates
infection rates; does not
capture data on relevant
differences
Limited value in small facilities
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 Various Methods of Surveillance Used in Infection
Control
Strategy Pros Cons
Site-specific Flexible and can be combined No defined prevention
with other strategies strategies or objectives

Identifies risk factors Denominator may be

inadequate
Unit specific Focuses on patients at greater May miss clusters
risk
Denominator may be
Simplified and reduces inadequate
personnel
Objective or priority-based Can be adaptable to facilities Baseline infection rates are
with special populations or not available
resources
May miss clusters or
Focuses on specific issues at outbreaks
the facility

Identifies risk factors

Adapted from: Perl TM, Chaiwarith R. Surveillance: An overview. Practical Healthcare Epidemiology, 3rd Ed., pp. 111-142, Chicago, IL: University of Chicago Press, 2010.
 Types of Surveillance: Outcome Surveillance

 Objective: COUNT number of HAI

 Informs the magnitude of the problem

Disadvantages:
 No information on what factors contribute to the
problem
 No internationally agreed definitions on surveillance
 Most commonly used: CDC/NHSN (USA) and ECDC (Europe)
 Assumes availability of good diagnostic laboratory support

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 Types of Surveillance: Process Surveillance

 Objective: MONITOR adherence to evidence-based or

best practices
 Essential to prioritize which processes/steps to monitor

Disadvantages:
 Reliability of data
 Good compliance does not equate with effectiveness

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 Example of Outcome vs. Process Surveillance

Maximum
Hand Skin Barrier
Hygiene Disinfection Precautions

PROCESS SURVEILLANCE OUTCOME

SURVEILLANCE
Counting number
Monitoring compliance with CVC care bundle elements
of CR-BSIs

Daily
Optimal Review
catheter site
selection

Adapted from Damani, N. Manual of Infection Prevention and Control, Third Edition.
New York: Oxford University Press, 2012.
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 Recommended Minimum Elements in a Data Set
for Surveillance

 Patient /resident information

– Name or unique identifier, DOB, sex, MRN, ward or unit in facility,
name of consultant, date of admission, onset date, date of
discharge or death, site of infection/colonization, organism
isolated with antibiotic sensitivities

 Medical treatment/procedures
– At time of infection
– Underlying medical risk factors, clinical outcome, assessment of
whether the incident was preventable

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Linelist: Example

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 Considerations

 All types of surveillance are expensive and time-

consuming

 Essential that definitions and objectives of surveillance

must be agreed with the clinical team

 Identify resources

 Personnel involved in surveillance must be trained

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 Summary

 Assess population and identify those at greatest risk

for outcome or process of interest

 Select outcome or process for surveillance

– Examples of outcomes: HIA, infection or colonization with a
specific organism, sharps injuries
– Examples of processes: Central line insertion practices, influenza
vaccination rates, personnel compliance with protocols

 Determine observation period

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 Summary (continued)

 Choose surveillance methodology

 Monitor for outcome or process using standardized

definitions for all data collected

 Collect appropriate denominator data, if rates are to be

calculated

 Analyze data

 Report in a timely manner

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 References
Damani, N. Manual of Infection Prevention and Control, Third Edition. New York:
Oxford University Press, 2012.

DHHS/CDC . Outline for Healthcare-Associated Infections Surveillance, 2006.

Tokars JI, Richards C, Andrus M, et al. The Changing Face of Surveillance for Health
Care—Associated Infections. Clinical Infectious Diseases 2004; 39: 1347-52.

Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care—
associated infection and criteria for specific types of infection in the acute care
setting. American Journal of Infection Control 2008; 36:309-32.

Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and
control programs in preventing nosocomial infection in US hospitals. (SENIC study).
American Journal of Epidemiology 1985; 121(2):182-205.

Lee TB, Montgomery OG, Marx J, et al. Recommended practices for surveillance:
Association for Professionals in Infection Control and Epidemiology (APIC), Inc.
American Journal of Infection Control 2007; 35(7):427-40.

HICPAC guidance on public reporting of healthcare-associated infections:

Recommendations of the Health care Infection Control Practices Advisory
Committee. Infection Control Hospital Epidemiology 2005; 26(6):580-7.
“Good surveillance does not necessarily
ensure the making of right decisions,
but it reduces the chances of wrong
ones.”

-Alex Langmuir, NEJM 1963: 268:182-191

MEASURES OF DISEASE
FREQUENCY
“One’s knowledge of science begins
when he can measure what he is
speaking about and express it in
numbers”

Lord Kelvin 1824-1907

 Measures in General

 Count
 Ratio
 Proportions
 Rate
 EPIDEMIOLOGIC MEASURES
Measures of frequency
 Incidence
 Prevalence
 Interrelationship between incidence and
prevalence
 COUNT

Simple measure of quantity

Example: The number of catheter-related bloodstream

infections (CR-BSIs) in Facility X in 2012.
 RATIO

An expression of the relationship between a numerator

and a denominator where the two are separate and
distinct quantities.

Example: Injurious falls occur in twice as many women

aged 65-69 years as in men of the same age group.

Ratio of women to men is 2/1 or 2:1

 PROPORTION

A type of ratio in which the numerator is

included in the denominator.
 EXAMPLE OF PROPORTION

 650 HIV+ patients were seen at Facility X.

 130 of these patients had Pneumocystis

carinii pneumonia (PCP).

 Proportion of HIV+ patients seen at Facility X with

PCP is 130/650.

 130/650 *100 = 20%

 RATE

An expression of the frequency with which an event

occurs in a defined population.

A measure of time is an intrinsic part of

the denominator.
 EXAMPLE OF RATE

435/1,000 elderly individuals residing in assisted living

facilities had colds in January.

(The 435 elderly residents with colds are part of the

1,000 residents in assisted living facilities.)
 TYPES OF RATES

Morbidity rates measure the frequency of

illness within a specific population.
 Incidence
 Prevalence
 Attack rate
Mortality rates measure the frequency of
death within a specific population.
 Crude death rate
 Cause-specific death rate
 Case-fatality rate
 MEASURES OF DISEASE FREQUENCY

Measures that characterize the occurrence of disease,

disability or death in populations.

 Incidence
 Prevalence
 MEASURES OF DISEASE FREQUENCY

 Incidence (I): Measures new cases of a disease or

health event that develop over a period of time.

 Prevalence (P): Measures existing cases of a

disease at a particular point in time or over a period
of time.
 INCIDENCE

The number of new cases of disease

that occur in a specified period of time.

There are two kinds of incidence measures:

 Cumulative incidence (CI)
 Incidence density (ID) or incidence rate (IR)
 CUMULATIVE INCIDENCE

The proportion of unaffected individuals who contract

disease during a specified time.

CI = # of new cases in a given time

Total population at risk

(Estimate of individual risk)

 PROBLEMS WITH USING CI

 To accurately calculate CI we need to follow the entire

population for the specified time interval.
 This is rarely possible for two main reasons
 People move in and out
 People may die from diseases other than disease of
interest
 INCIDENCE RATE

The instantaneous potential for change in disease status

per unit of time.

IR = # new case in a given time

Total person-time of observation

Ranges from 0 to 
 WHAT DENOMINATOR DATA TO COLLECT?

For device-associated HAI incidence rates:

 Daily total number of patients AND
 Total number of ventilator-days, central line-days, and
urinary catheter-days in patient care area(s) under
surveillance
 Sum daily counts at the end of the surveillance period
for use as denominators

Denominator data may be collected by someone other

than the ICP as long as that person is trained
 INCIDENCE RATE EXAMPLE

Three people out of ten persons observed develop

disease during a 30-day period of follow-up.

The cumulative rate = 3 cases in 30 days

10 people

or 1 per 100 per day

(3/10 = 0.3 * 100 = 30/30 days = 1 = incidence for one day per 100
people)
 ATTACK RATE

 Another type of incidence rate

 Expressed as cases per 100 population (or a
percentage)
 Used to describe the new and recurrent cases of
disease that have been observed in a particular group
during a limited time period in special circumstances,
such as during an outbreak

 Attack rate:
Number of new and recurrent cases in a specified time period
X 100
Population at risk for same time period

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 PREVALENCE

 Measures existing cases of a health condition

 Two types of Prevalence

 Point prevalence
 Period prevalence
 POINT PREVALENCE

 Point Prevalence = C / N

Where C = Number of observed cases at time t

And N = Population size at time t

Point prevalence measures the frequency of disease at a

given point in time.
 POINT PREVALENCE
EXAMPLE

 Suppose there are 150 individuals in a population and,

on a certain day, 15 are ill with the flu. What is the
estimated prevalence for this population?

 P = 15/150 = 10%
 PERIOD PREVALENCE

 Period Prevalence = [C + I] / N

 C = the number of prevalent cases at the beginning of

the time period.

 I = the number of incident cases that develop during

the period.

 N = size of the population for this same time period.

 EXAMPLE

What is the prevalence of disease X on January 1, 1992?

Point Prevalence = C/N = 0/10 = 0%
 EXAMPLE

What is the period prevalence of disease X between 1990 and 1995?

Period Prevalence = [0 + 5] / 12 = 42%
 PREVALENCE

Useful for:
 Assessing the health status of a population.
 Planning health services.

Not Useful for:

 Identifying risk factors
 ANOTHER EXAMPLE

Suppose we followed a population of 150 persons for one

year, and 25 had a disease of interest at the start of follow-up
and another 15 new cases developed during the year.

What is the point prevalence at the start of the period?

What is the period prevalence for the year?

What is the point prevalence at the end of period?

What is the cumulative incidence for the one year period?

 ANOTHER EXAMPLE

Suppose we followed a population of 150 persons for one

year, and 25 had a disease of interest at the start of follow-up
and another 15 new cases developed during the year.

What is the point prevalence at the start of the period?

25/150 = 0.17 = 17%

What is the period prevalence for the year?

(25 + 15) / 150 = 0.27 or 27%

What is the point prevalence at the end of period?

Not known

What is the cumulative incidence for the one year period?

15/125 = 0.12 = 12%
 FACTORS THAT INCREASE PREVALENCE

 Cases move into population

 Healthy people leave population
 Longer living with disease
 Longer duration of disease
 Increased number of susceptible/at-risk individuals
 FACTORS THAT DECREASE PREVALENCE

 Cases move out of population

 Healthy people move into population
 People being cured
 Shorter duration of disease
 Decreased number of susceptible/at-risk individuals
 INTERRELATIONSHIP BETWEEN INCIDENCE AND
PREVALENCE

Prevalence depends on both incidence and disease

duration.

If the incidence is low but the disease duration is

long, the proportion of the population with
the disease at a particular time is high
compared to the incidence.
 EXAMPLE OF INTERRELATIONSHIP

In the beginning of the AIDS epidemic, the incidence

rate of AIDS increased quickly. However, the disease
duration was short because everyone died in a few
years. Therefore, the prevalence was low.

 Incidence and  duration =  prevalence

 EXAMPLE OF INTERRELATIONSHIP

Today, the incidence rate is not increasing as quickly

but the duration of survival is considerably longer.
Therefore, the prevalence is now much higher.

 Incidence and  duration =  prevalence

 PREVALENCE AND INCIDENCE

When the disease is stable:

Prevalence = Incidence * Disease Duration

 Incidence vs. Prevalence

Incidence (I): Measures new cases of a

disease that develop over a period of time.

Prevalence (P): Measures existing cases of a

disease at a particular point in time or over a
period of time.
 Prevalence vs. Incidence

 Prevalence can be viewed as describing a pool of

disease in a population.

 Incidence describes the input flow of new cases into the

pool.

 Fatality and recovery reflects the output flow from the

pool.
 SUMMARY

 Risk (cumulative incidence) is the probability that an

event will occur within a given time-interval

 Rate (incidence rate) is a measure of how rapidly the

events occur in a population

 In contrast to measures of incidence (risk and rate),

prevalence deals with existing (as opposed to newly
occurring) health-related states
Linelist: Example

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