Epidemiology's contribution to health service management and planning in developing countries: a missing link.

Two hypotheses are examined in the light of experience and the literature: (1) health service planning requires little epidemiological information, and (2) health services rarely get useful answers to relevant epidemiological questions. In the first hypothesis, the theoretical robustness of the concept of a minimum package of activities common to all facilities belonging to the same level of the system and the extent to which it is unaffected by variations in the frequencies of most diseases are examined. Semi-quantitative analyses and analysis of routine entries and participation suffice to adapt this package to the local context. Some of the methods which give a fundamental role to epidemiological information are criticized. With regard to the second hypothesis, the pertinent contributions epidemiology may make to health service organization are reviewed. These include identification of diseases that justify special activities (health maps and interepidemic surveillance), determination of the activities that should be added to the health centres, the political usefulness of rare impact assessments, and the relevant demographic elements. Finally an epidemiological agenda is proposed for specialized centres, districts, universities, and the central decision-making level of health ministries in developing countries.     

Cost and performance of malaria surveillance in Thailand

Some results are presented from a study to determine the costs and performance of the antiparasite elements of the malaria disease control programme in Thailand. Issues examined in the paper are the concept of cost-effectiveness and its relevance in evaluating health care processes, procedures for measuring the performance of malaria surveillance and monitoring processes and procedures for measuring costs. Some data on the costs and the performance of operational services and control activities in two malaria zones are presented and the paper closes by considering how health economics research can be stimulated and supported in developing countries. It is argued that the cost-effectiveness of malaria surveillance and monitoring processes (and probably many other health care processes) can not be measured retrospectively. In the case of malaria control the effectiveness of each operational services can not be compared because services provided are interactive and complementary rather than alternatives. In addition the targets set and levels of effectiveness achieved may not be the same for these complementary processes. Procedures developed for measuring the performance and costs of malaria operational services and activities are described. Five types of measurement are used to evaluate the performance of the operational services and activities; effectiveness (%); time (days); performance (%); and efficiency (cost/unit). Actual expenditure on malaria operational services and activities is not known since all expenditure of government departments in Thailand is recorded under nine budget headings. Budget expenditure at division, region and zone levels must therefore be apportioned to assess the costs of operational services and activities. Since a variety of criteria may legitimately be used to apportion costs at each level, a network technique was developed which allows examination of the effect of all possible combinations of criteria. By this means the maximum, minimum and most appropriate costs are determined. Examples of the costs and performance of surveillance operational services and activities in two zones are presented. Data illustrates the outcomes from the procedures developed and indicates how malaria disease control managers might interpret and use the information obtained. The paper closes with some observations on how health economics research in developing countries could be better stimulated and supported through staff development programmes and through supervised 'on the job' training.     

Pandemic planning at the coal face: responsibilities of the public health unit

Responding to an infectious disease pandemic requires a coordinated approach from all essential services. Public health units across NSW will play an important role in a range of control activities. These include: surveillance, education, communication, case ascertainment, case management (excluding clinical management), infection control, contact tracing, monitoring contacts in home quarantine, surveillance at borders, epidemiological studies and immunisation. Public health units are currently planning for such an emergency and these plans will need to be tested and refined under simulated conditions.     

Epidemiology and health services

The growing application of epidemiological investigation to the health and medical field has consolidated its various uses in health care services. Brazilian legislation now provides back-up for four different types of applications, although their implementation is still precarious: analysis of the health situation, epidemiological surveillance, etiological studies, and evaluation of health care services, programs, and technologies. Proper deployment of such epidemiological applications on both the political/institutional and operational levels will provide relevant subsidies for health services in conducting their activities.     

Real time information. A necessary tool in epidemiological surveillance

Since 2004 an electronic epidemiological surveillance system (AVE) has been developed and implemented for infectious diseases in the autonomous region of Valencia that allows data collection from notifiable diseases in real time concerning outbreaks and alerts, as well as analysis and dissemination of the information. Within the autonomous region of Valencia, the system is used by 17 epidemiology units, which act as the first level of specialized surveillance. The electronic surveillance system is used by all these units, as well as by physicians working in primary and specialized care, who can introduce information from the ambulatory information system while the patient is in the practice room. The system is able to capture the demographic data from the patient and the physician can add any other information that is considered important for the case detected. The system receives new laboratory test results overnight from the Microbiological Surveillance Network (RedMIVA). AVE can record outbreaks of notifiable diseases as well as any unusual clusters or changing patterns of any disease. The department of epidemiology has access to the whole system for analysis of the information and for quality control of the epidemiological surveillance. The system provides timely and comprehensive information to facilitate public health action in individual cases of infectious disease.     

Epidemiological surveillance activities during the 2009 influenza pandemic in Spain: lessons learnt one year after

In this article the actions taken in the area of epidemiological surveillance in Spain during the influenza pandemic and the recommendations drawn from them during the progression of the pandemic are reviewed. The performance of the Surveillance Subcommittee established in the National Influenza Preparedness and Response Plan was central to the coordination of these activities. The Surveillance Subcommittee was immediately activated when the alert was issued. Its role is also described in this review. The existence of a National Plan allowed a rapid and coordinated response after the alert declaration. The epidemiological and virological surveillance of the influenza pandemic was adapted to an evolving situation. In addition to routine influenza monitoring systems, new surveillance systems were put in place such as a case-based surveillance for community influenza cases and a case-based surveillance for severe cases and deaths due to the pandemic. Among the lessons learned from this pandemic, we would highlight the need to strengthen the timely analysis of data collected during an alert, the need to promote the exchange of information among public health and health care professionals, and to strengthen the response capacity in order to have resilient and consolidated public health structures for future health alerts.     

Überblick und Bewertung der verfügbaren Datenquellen zur Inzidenz impfpräventabler Krankheiten, zum Durchimpfungsgrad und zum Immunstatus in Deutschland

The surveillance of vaccine preventable diseases and vaccination coverage is necessary in order to deliver epidemiological data with respect to national vaccination recommendations and control targets. The data available on the incidence of vaccine preventable diseases, vaccination coverage, and immune status of the population are fragmentary and do not allow the epidemiological situation to be fully assessed. Although the majority of vaccine preventable diseases are under surveillance nationwide (by statutory reporting or sentinel surveillance), data are not available for some diseases. In addition, data on vaccination coverage are not collected centrally. Nationwide data on vaccination coverage are only available for children at school entry. Use of secondary data such as data from health insurance companies or associations of statutory health insurance physicians provides an opportunity to close gaps in knowledge and to improve the surveillance of vaccine preventable diseases.     

Public health structures in Spain: a changing panorama]

In the last years the health care system in Spain has undergone very important transformations. However, the public health services have not followed a comparable process. Until 1979 public health structures were based in central services and their provincial units, on one side, and in the resources of local governments on the other. From then on began the process of transferring responsibilities and resources to the regional governments of Autonomous Communities (AC), which today manage most public health services, while the central government keeps as its responsibility the development of basic norms, the administration of public health services at borders and customs, and the general health coordination. The situation in 1995 resembles that of a Federal Country, although the Kingdom of Spain is not formally defined as such. The role of central government services is visibly reoriented towards coordination and the building of consensual and shared structures for health information, for need evaluation, and for policy formulation and evaluation. Although the General Health Law of 1986 considered public health as a main axis for all health agencies, its actual development has been more patchy. Several AC with an Autonomous Health Service have kept public health services separated from it. Besides, many public health functions and activities are developed today from other structures. The processes of change reveal two contradictory aspects. On one side, structures have been upgraded after decentralization, and teams reinforced, with trained and full-time staff. However, there is some dilution of public health responsibility in the periphery, and a lower visibility of the health authority.     

内蒙古自治区2009年麻疹流行病学特征分析和控制策略探讨

目的了解2009年内蒙古自治区麻疹流行病学特征,提出麻疹控制措施。方法根据疾病监测信息报告管理系统和麻疹脏测信息专报系统,对2009年麻疹疫情资料进行描述流行病学分析。结果内蒙古自治区2009年麻疹发病率开始下降,报告麻疹病例1 456例,发病率为6.03/10万,15岁人群发病数占48.21%,确诊病例中有麻疹疫苗免疫史占25.34%。结论保持高质量的麻疹疫苗常规免疫,适时的开展全区强化免疫活动,提高监测系统的灵敏性是控制和消除麻疹的关键策略。     

Facilitating factors and difficulties in the the implementation of sanitary surveillance of drugstores in Salvador, state of Bahia, Brazil

Drugstores are the health establishments where medications are dispensed, which is why sanitary surveillance is justified as a means of intervention. The health department uses various technologies to control risk in drugstores. In this study we used the theory of the process of work in health as a benchmark in order to describe and analyze the strengths and difficulties encountered in sanitary surveillance in drugstores in Salvador. Case study methodological strategy was adopted, the analytical categories being facilitating factors and difficulties inherent to technicians, drugstore, sanitary surveillance service and the social environment. Data were collected through direct observation techniques and semi-structured interviews, and the findings were assessed using content analysis. The body of information was processed and categorized using QSR N VIVO software. It was revealed that the nature of the facilitating factors and difficulties found in surveillance activities of drugstores indicate the need for urgent change within the scope of services and the sanitary culture in the country. It also stresses the possibilities of offering a quality service for the protection of health, in a setting conducive to the development of sanitary surveillance and the process of decentralization of these actions.     

Environmental surveillance in health in Brazil's Unified Health System

The incorporation of environmental surveillance in the field of public health policies is a relatively recent demand in Brazil. One of the major challenges in environmental health surveillance is defining its object and the specificity of its practice. The expanded concept of exposure, treated as a set of complex relations between a society and the environment, and not as a personal attribute, is central to the definition of indicators and should guide the practice of environmental surveillance in the health sector. Among the difficulties encountered in applying this concept within the Brazilian Health System, is the need to restructure health surveillance activities and to form multidisciplinary teams capable of dialoguing with other sectors. Furthermore, information systems capable of aiding in health situation analysis and decision making must be constructed. Taking this into consideration, a review of the object and concepts of environmental health surveillance was undertaken and the challenges with respect to its implementation in the Brazilian Health System were identified.     

创建流行病学监测系统基本流程的探讨

目的总结创建流行病学监测系统的基本流程。方法先将系统科学、信息科学、控制科学等学科的相关理论进行演绎推理,总结监测系统创建应包含的基本流程。再以50个现有流行病学监测系统为研究对象并以流行病学监测的性质为指导,进行归纳推理完善这一过程。结果流行病学监测系统基本流程主要包括：系统分析、系统逻辑模型建立、系统设计、系统实施、系统评价、系统完善。结论流行病学监测系统创建的各个环节缺一不可,有机结合,才能确保创建高效的流行病学监测系统。     

Changes in the role of general practitioners in child health surveillance

Background: Changes in their Contract in 1990 gave general practitioners the opportunity to become more involved in child health surveillance. This study aimed to describe and compare child health surveillance services provided by general practitioners before and after the changes of the 1990 GP contract.Methods: A questionnaire was sent to all general practices within the Nottingham Health Authority area in 1990, and this process was repeated in 1994, ascertaining the services provided for child health surveillance. Outcome measures were: the reported provision of services, keeping of records and facilities for following up non-attenders. Also recorded were the training and qualifications of general practitioners and their attitudes towards child health surveillance.Results: Response rates were 62% in 1990 and 80% in 1994. More practices were involved in the provision of child health surveillance services in 1994, more held a baby clinic and more reported having a recall system for non-attenders. There was little change in the training or qualifications of GPs in child health between 1990 and 1994. In 1994, there was evidence of GPs meeting regularly with Health Visitors. There remained a small number of practices who were not interested in child health surveillance.Conclusion: The 1990 GP contract appears to have increased the provision of child health surveillance services by GPs and improved liaison with Health Visitors in general practice.     

Pilot study on compulsory vaccination coverage

The disappearance of diphtheria and poliomyelitis is the best evidence of the efficacy of the vaccination strategies adopted in Italy. The active offer of the prophylaxis, reinforced by law, has characterised the operational aspects of the strategy. The active surveillance system is the main tool to take under control the effectiveness of health services responsible for vaccination. This system could be more easily implemented if the health services will be given a specific software aiming to handle and evaluate vaccination registers. The present pilot study, performed in the regions Marche and Sardegna, is an example of active surveillance and it is based on the ARVA software produced by the Istituto Superiore di Sanità. The results show a good level of coverage (> 95%) within the second year of life. Unsatisfactory results were obtained on the timing of vaccinations, as recommended by the vaccination schedule, mostly for the third doses.     

Relations between official and private veterinary services in epidemiology and the control of contagious diseases

Growing budget restrictions in many countries have meant that official Veterinary Services cannot assume responsibility for any new activities. The natural reaction is to turn to private veterinary services to provide the support needed to strengthen the control and surveillance of priority diseases and thereby support the development of the livestock sector and the establishment of safe international trade. In this context, official Veterinary Services must work together with private veterinarians, delegating various technical animal health activities, so that they may focus their efforts on those tasks that cannot be delegated: standardisation, control, auditing, general system co-ordination, epidemiological surveillance, etc., as well as organising veterinary policy in order to make best use of budget resources. For these relations to be efficient, a dynamic, two-way epidemiological information mechanism must be created, whereby private veterinarians periodically keep governments informed, on the basis of an agreed methodology. Moreover, the official Veterinary Services must systematically transmit information on List A and B diseases of the OIE (World organisation for animal health), and perform detailed analyses of epidemiologically significant events. The article proposes the establishment of relations between public and private veterinary services as a way in which to provide the livestock sector with the health and hygiene conditions that are necessary for effective disease control, which in turn provides greater security for international trade and increased consumer protection.     

Epidemiological intelligence as a model of organization in health

The concept of epidemiological intelligence, as a construction of information societies, goes beyond monitoring a list of diseases and the ability to elicit rapid responses. The concept should consider the complexity of the definition of epidemiology in the identification of this object of study without being limited to a set of actions in a single government sector. The activities of epidemiological intelligence include risk assessment, strategies for prevention and protection, subsystems of information, crisis management rooms, geographical analysis, etc. This concept contributes to the understanding of policies in health, in multisectorial and geopolitical dimensions, as regards the organization of services around public health emergencies, primary healthcare, as well as disasters. The activities of epidemiological intelligence should not be restricted to scientific research, but the researchers must beware of threats to public health. Lalonde's model enabled consideration of epidemiological intelligence as a way to restructure policies and share resources by creating communities of intelligence, whose purpose is primarily to deal with public health emergencies and disasters.     

Strengthening vaccination policies in Latin America: An evidence-based approach

Despite many successes in the region, Latin American vaccination policies have significant shortcomings, and further work is needed to maintain progress and prepare for the introduction of newly available vaccines. In order to address the challenges facing Latin America, the Commission for the Future of Vaccines in Latin America (COFVAL) has made recommendations for strengthening evidence-based policy-making and reducing regional inequalities in immunisation. We have conducted a comprehensive literature review to assess the feasibility of these recommendations. Standardisation of performance indicators for disease burden, vaccine coverage, epidemiological surveillance and national health resourcing can ensure comparability of the data used to assess vaccination programmes, allowing deeper analysis of how best to provide services. Regional vaccination reference schemes, as used in Europe, can be used to develop best practice models for vaccine introduction and scheduling. Successful models exist for the continuous training of vaccination providers and decision-makers, with a new Latin American diploma aiming to contribute to the successful implementation of vaccination programmes. Permanent, independent vaccine advisory committees, based on the US Advisory Committee on Immunization Practices (ACIP), could facilitate the uptake of new vaccines and support evidence-based decision-making in the administration of national immunisation programmes. Innovative financing mechanisms for the purchase of new vaccines, such as advance market commitments and cost front-loading, have shown potential for improving vaccine coverage. A common regulatory framework for vaccine approval is needed to accelerate delivery and pool human, technological and scientific resources in the region. Finally, public–private partnerships between industry, government, academia and non-profit sectors could provide new investment to stimulate vaccine development in the region, reducing prices in the long term. These reforms are now crucial, particularly as vaccines for previously neglected, developing-world diseases become available. In summary, a regionally-coordinated health policy will reduce vaccination inequality in Latin America.     

An evaluation of the Ontario Rapid Risk Factor Surveillance System

BACKGROUND: The Rapid Risk Factor Surveillance System (RRFSS) is an ongoing population health survey conducted by a collaborating group of Ontario public health units. This formative evaluation examined the process effectiveness, collaboration, utility and cost-effectiveness of RRFSS during its first year of operation. METHODS: An Evaluation Framework was developed with reference to guidelines for evaluation of surveillance systems developed by the World Health Organization and the U.S. Centers for Disease Control and Prevention. The study focussed on evaluable performance areas in a young surveillance system and on information needed to inform stakeholder decisions about future participation and improvement. Data were collected through surveys and interviews of key informants in participating health units, non-participating health units, the survey research house, and the provincial health ministry. RESULTS: Findings documented early use and dissemination of RRFSS data in health units after less than a year of surveillance system operation, stakeholder perceptions overall of data impact and value, and satisfaction with system functioning. Challenges to effectiveness were documented concerning data analysis, barriers to data use, and sustainability. Performance improvement strategies were identified for survey implementation and supports, data use, system participation, and reduced costs. CONCLUSION: In its first year, RRFSS was an effective collaborative method to collect population data for public health program planning and evaluation. The evaluation provided valuable information on use, functioning, effectiveness, strategic issues and areas for improvement in a young surveillance system, created opportunities for stakeholder input into evaluation and planning, and provided a baseline for future evaluations.     

Worker's Health Surveillance

This paper is part of a broader discussion on the need for more in-depth study of workers' health surveillance practices, which are most often developed empirically, without well-defined theoretical or technical foundations. The paper presents a concept of surveillance in workers' health as a fulcrum for actions in the relationship between the work process and health. It emphasizes the exposure-based perspective involved in the epidemiological approach. Risk situations and effects are placed in spatial and technological context. The model provides an interdisciplinary approach with a technological, social, and epidemiological basis in a three-dimensional structure. A matrix for planning actions in workers' health surveillance is also presented, focusing on the connections between effects, risks, territory, and activities.