Sexually Transmitted Diseases  >  Program Guidelines  >  Surveillance and Data Management

Program Operations Guidelines for STD Prevention
Surveillance and Data Management

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Sections on this page:

• METHODS OF SURVEILLANCE
• Passive Surveillance
• Active Surveillance
• Sentinel Surveillance
• Special Systems
• SURVEILLANCE SYSTEM ATTRIBUTES
• PERSONNEL, TRAINING, AND RESOURCES

METHODS OF SURVEILLANCE

Surveillance methods can be divided into four general categories: passive, active, sentinel, and special systems. In general, passive and active systems are based on conditions that are reportable to the health jurisdiction. Sentinel systems and special systems are usually designed to obtain information that is not generally available to health departments.

Passive Surveillance

Passive surveillance is the most common form of surveillance and relies on standardized reporting forms or cards provided by or available through the state or local health departments. These completed forms are returned to the health department when cases of disease are detected. The term passive is used to convey the idea that health authorities take no action while waiting for report forms to be submitted. It is also a potentially misleading term, since case reporting is not a passive activity for the reporter, who must complete the form. Additionally, case reports received by the public health authority may require further action to ensure completeness, proper case classification, and partner management.

Passive reporting systems are generally less costly than other reporting systems, data collection is not burdensome to health officials, and the data may be used to identify trends or outbreaks if providers and laboratories report. Limitations include non-reporting or under-reporting, which can affect representativeness of the data and thus lead to undetected trends and undetected outbreaks. A positive test may not be reported to prevent the stigmatization associated with STD, because of a lack of awareness of reporting requirements by health care providers, or the perception on the part of the health care provider that nothing will be done. Incomplete reporting may reflect lack of interest, surveillance case definitions that are unclear or have recently changed, or changes in reporting requirements. Incomplete reporting also may be a result of the patient not being willing to provide the information or hardware/software systems that cannot capture the information in databases.

Active Surveillance

Active surveillance involves outreach by the public authority, such as regular telephone calls or visits to laboratories, hospitals, and providers to stimulate reporting of specific diseases. Because it places intensive demands on resources, implementation of active surveillance should be limited to brief or sequential periods of time and for specific purposes. It is a reasonable method of surveillance for:

• conditions of particular importance - to document a suspected outbreak, or to augment timely disease intervention or epidemiologic investigation (e.g., for congenital syphilis in certain jurisdictions);
• episodic validation of representativeness of passive reports and as a departure point for enhancing completeness and timeliness of reporting (e.g., lab visitation programs to ensure all reactors reported);
• diseases targeted for elimination or eradication (e.g., smallpox, syphilis).

Operationally, active surveillance includes visits or telephone calls to such key reporting sources as clinicians or laboratories by public health authorities on a regular or episodic basis to elicit (or verify) case reports and/or reviewing medical records and other alternative sources to identify diagnoses that may not have been reported. It is generally employed when it is expected that more disease is in the community than is shown in the passive surveillance systems.

Sentinel Surveillance

Sentinel surveillance involves the collection of case data from only part of the total population (from a sample of providers) to learn something about the larger population, such as trends in disease. The advantages of sentinel surveillance data are that they can be less expensive to obtain than those gained through active surveillance of the total population, and the data can be of higher quality than those collected through passive systems. This is because it is logistically easier to obtain higher quality information from a smaller population. A vulnerability of sentinel systems is not being able to ensure the representativeness of the sample selected. Sentinel surveillance systems may be useful in identifying the burden of disease for conditions that are not reportable, or behavioral characteristics that are of sufficient public health importance to merit monitoring. Candidates for sentinel systems might include: human papilloma virus, herpes simplex primary infection, congenital infection, or other adverse outcomes of STDs. One sentinel surveillance system already in place is the Gonococcal Isolate Surveillance System (GISP), which monitors the antibiotic resistance patterns of gonococcal isolates in selected sites by clinic-type, patient characteristics, and changes over time. Sentinel systems for antimicrobial resistance patterns for chlamydia, herpes, and trichomoniasis may be useful, as would sentinel surveillance of relevant risk behaviors.

Special Systems

Special systems are occasionally designed and implemented to generate surveillance information that is not possible to acquire by any of the other systems already mentioned. Special systems include those designed for chlamydia prevalence monitoring, which consist of collection of information regarding all tests performed—positive or negative—to determine the number of infections in the population at risk over a particular time interval (period prevalence). Because chlamydia is only diagnosed by testing, the population at risk for a chlamydia diagnosis is defined as those tested for chlamydia.

SURVEILLANCE SYSTEM ATTRIBUTES

The MMWR Supplement, dated May 6, 1988, titled: Guidelines for Evaluating Surveillance Systems describes surveillance system attributes in detail. Each surveillance system has elements that are designed to meet specific objectives. The combination of these attributes determines the strengths and weaknesses of the system. The attributes must be balanced against one another (e.g., high sensitivity may be possible only with a complex reporting system from a wide array of providers). Appendix S-E describes these attributes.

PERSONNEL, TRAINING, AND RESOURCES

Historically, STD prevention programs have put most of their surveillance resources into data collection and data management functions rather than into data analysis, interpretation, and dissemination. Although data collection and data management are the foundation of surveillance, data alone are not meaningful without appropriate analysis, interpretation, dissemination, and application of surveillance data. These surveillance functions are critical to making informed decisions on quality of case report or prevalence data, applying science-based information to local program's prevention and intervention strategies, and increasing data completeness and quality within and across STD prevention programs.

Many state and local STD prevention programs, however, have no one assigned to data analysis and interpretation functions. Every program must have or must develop the capacity to properly collect, assess, analyze, interpret, and disseminate surveillance data. This requires individuals with specific training or expertise. Toward this end, programs should cooperate with local, state, and federal agencies to implement the approaches necessary to have or develop these skills in STD prevention programs.

Designation of a surveillance coordinator in each project area provides a focal point for developing analytical capacity. The surveillance coordinator should be made responsible for building analytical and data interpretation capacity. Recommendations on building capacity and on training recognize the limited resources that can be allocated to these necessary activities. These recommendations thus indicate the use of innovative approaches to staff training that will require cooperation between STD prevention programs and all levels of the public health system. Improvements in a STD prevention program's capacity to analyze and interpret surveillance data will likely save money over time because of improved data quality and availability—allowing for data-based prevention program  planning.

A variety of options can be explored to help programs meet identified training and resource needs associated with the development of a surveillance coordinator position. These may include:

• providing training and supervision by other program staff who have appropriate expertise;
• cross-training persons within the health department to take advantage of expertise in other programs (e.g., STD, HIV, or communicable diseases) and public health disciplines (e.g., epidemiology, biostatistics, or program management) and to improve surveillance capacity without requiring additional hiring;
• promoting and providing technical assistance to other less-developed programs by using experienced staff from those programs that have enhanced surveillance capacity or from other public health-affiliated organizations such as CSTE;
• using training opportunities sponsored by local health department(s), distance learning, train-the-trainer programs, teleconferences, Internet based modules, EpiInfo or other workshops, attendance at academic-sponsored workshops and seminars, co-operative agreements between the STD prevention programs and Schools of Public Health or other academic departments;
• sponsoring academic training for staff as deemed necessary and appropriate; and
• checking with Surveillance and Data Management Branch, Division of STD Prevention, CDC, for additional sources of training.

The role and related responsibilities of the Surveillance Coordinator should be determined by program needs and individual employee skills and experiences, but that role could be expected to include:

• designing, reviewing, and revising of STD surveillance system procedures and written protocols on provider-based reporting, laboratory-based reporting, and quality assurance, including provider and laboratory visitation efforts;
• coordinating data collection, management, and reporting for case-reporting data, prevalence-monitoring data, and sentinel systems such as the Gonococcal Isolate Surveillance Project (GISP);
• coordinating quality assurance activities for completeness, validity, and timeliness;
• designing information systems that have adequate capacity, and integrity;
• analyzing and interpreting data;
• disseminating data;
• evaluating the STD surveillance system annually;
• conducting active surveillance, as indicated.

Although provider and laboratory visits may be shared by program staff, the surveillance coordinator should be responsible for supervising these activities. Therefore, the surveillance coordinator should be versed in these skills or afforded training that includes observing visits performed by experienced staff and then being observed.

Long-term collaboration addressing staff training and career development to support common surveillance goals and tasks is difficult without formal relationships. Formal collaboration refers to joint activities based on a) written agreements, contracts, or memoranda of understanding; b) shared grant goals and objectives (e.g., Infertility Prevention Projects and STD/HIV Prevention Training Center); or c) participation in program decision-making (e.g., state epidemiologist on an Infertility Prevention Project Executive Advisory Committee).

Some state health departments have elected to reorganize program activities to include interdisciplinary teams proficient in program evaluation and data analysis. These professional staff may not work solely in STD prevention programs but rather may provide technical services to improve assessment and quality assurance for several health department programs. STD prevention program efforts should be increased to use this expertise, where available.

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