GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH
History and evolution of surveillance in public health
1
Varun Kumar,* Deepak Raut
GJMEDPH 2014; Vol. 3, issue 1
ABSTRACT 1
Deepak Raut, Director Professor,
The modern concept of surveillance has evolved over the centuries. Public Department of Community Medicine,
health surveillance provides the scientific database essential for decision VMMC and SJH, New Delhi, India.
making and appropriate public health action. It is considered as the best *Corresonding Author
public health tool to prevent the occurrence of epidemics and is the Post Graduate student
backbone of public health programs and provides information so that Junior Resident
Department of Community Medicine
effective action can be taken in controlling and preventing diseases of public VMMC and SJH
health importance. This article reviews the history of evolution of public New Delhi, India
Email: drvarunkumar17@gmail.com
health surveillance from historical perspective: from Hippocrates, Black
Death and quarantine, recording of vital events for the first time, first field Conflict of Interestnone
investigation, legislations that were developed over time and modern
Fundingnone
concepts in public health surveillance. Eradication of small pox is an
important achievement in public health surveillance but the recent Severe
Acute Respiratory Syndrome (SARS) and Influenza pandemics suggest still there is a room for improvement.
Recently new global disease surveillance networks like FluNet and DengueNet were developed as internet
sites for monitoring influenza and dengue information. In spite of these developments, global public health
surveillance still remains unevenly distributed. There is a need for increased international cooperation to
address the global needs of public health surveillance.
Keywords: history, evolution, surveillance, public health
INTRODUCTION
Public health surveillance is considered to be an planning, implementation, and evaluation of public
essential public health function. Surveillance data are health practice3. Recent disease outbreaks like the
a result of continuous monitoring of the occurrence Severe Acute Respiratory Syndrome (SARS)
of a disease or condition. The term surveillance is pandemic, the avian influenza pandemic and the
derived from the French word meaning to watch alleged threats of deliberate epidemics like anthrax in
over. Public health surveillance provides the the wake of bioterrorism have brought together the
scientific database essential for decision making and countries in the field of public health to plan for a
appropriate public health action.1 Public health comprehensive surveillance agenda.
surveillance is considered as the best public health
tool to prevent the occurrence of epidemics.2 All outbreaks cannot be predicted or prevented.
However, precautionary measures can be taken
The modern concept of surveillance has evolved over within the existing health infrastructure and service
the centuries. World Health Organization (WHO) in delivery to reduce risks of outbreaks and to minimize
2012 defined Public health surveillance as the the scale of the outbreak, if it occurs. The
continuous, systematic collection, analysis and effectiveness with which national programs are
interpretation of health-related data needed for the implemented and monitored, the alertness for
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identification of early warning signals and the and other environmental agents, evaluation of
capacity for initiating recommended specific control measures, and to describe the natural history
interventions in a timely manner are important to of a health event in a community that will generate
achieve the above objectives. hypotheses and stimulate applied research4. In short,
public health surveillance is the foundation for
Surveillance is the backbone of public health program decision making in public health and empowers
and provides information so that effective action can decision makers to lead and manage more effectively
be taken in controlling and preventing diseases of by providing timely, useful evidence5. This article
public health importance. In some cases like cholera describes the evolution of surveillance from historical
and food contamination, the action must be perspective.
immediate, within hours in order to prevent large
scale epidemics and deaths. In others, control and Historical origins of surveillance:
prevention activities are long term response to The first recorded epidemic in history was the great
information about disease such as tuberculosis and pestilence in Egypt during 3180 BC. This was the
Non Communicable Disease risk factors, for which starting point of collecting and organizing data.
action may be taken in weeks, months or even years. Some of the major epidemics6 in the history of public
health are summarized in table 1.
Surveillance data also can be used to detect changes
in health practices, monitoring changes in infectious
Table 1. Major epidemics in the history of public health
S. No Year Places affected Disease
1 3180 BC Egypt The great pestilence
2 166 AD Rome Small pox
3 541 549 AD Constantinople The Justinian Plague
4 664 689 AD England Relapsing fever
5 1348 1351 AD Asia and Europe The Black Death (Bubonic Plague)
6 1494 AD Europe Syphilis
7 1500 1600 AD Americas Small pox
8 1600 1650 AD South America Malaria
9 1665 AD London The Great Plague of London
10 1817 1875 AD Worldwide Pandemics of cholera
11 1918 France, England, The Spanish Flu
China, United States
12 1940 now Worldwide Lung cancer epidemic
13 1957 Worldwide The Asian Flu
14 1983 Worldwide AIDS (Acquired Immune Deficiency Syndrome)
15 1997 now Worldwide Obesity pandemic
16 2003 Worldwide SARS (Severe Acute Respiratory Syndrome)
17 2007 Worldwide Influenza
The idea of collecting data, analyzing them, and Places, when writing on disease occurrence,
considering a reasonable response stems from Hippocrates made a distinction between the endemic
Hippocrates, a Greek physician who lived between state as the steady state of the disease, and the
460 370 BC. In his book, On Airs, Waters and epidemic as the abrupt change in incidence of
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disease.7 plague, establishing quarantine, issuing health
passes, arranging for the burial of plague victims and
Development of isolation as a public health tool the fumigation of their residences, and the
After the fall of Roman Empire in 476 AD, Europe management of lazarettos. The boards worked in
experienced a period of social and political coalition with the local physicians who provided
disintegration. There was a decline of hygiene and medical care and prophylactic advice. As time
sanitation and physical body became less important passed, the boards took control over markets,
than the spiritual self. Many epidemics occurred, the sewage systems, water supplies, cemeteries, and the
notable ones being small pox, plague, leprosy, cleanliness of streets; and they took jurisdiction over
measles and tuberculosis. So this period, the professional activities of physicians and surgeons,
approximately from 500 1500 AD is called as, Dark the preparation and sale of pharmaceutical drugs,
ages of medicine. and it also kept an eye on activities of beggars and
prostitutes. With the disappearance of plague at the
The concept of isolation as a tool in public health was end of the seventeenth century, the boards of health
developed during this period. Leprosy was the most disappeared but, they provided a model for
important disease of this period, manifested by a nineteenth century organization of public health
continent-wide epidemic which began in 6th century activities.8
and lasted till 15th.7 Rules and regulations were made
to diagnose the disease and isolate cases. Leper Recording of vital events:
houses (leprosaria) were established isolate cases of Records of vital events were preserved in numerous
leprosy in medieval times and it represents the European towns at the beginning of sixteenth
earliest application of a public health practice still in century. The first London Bills of Mortality were
use. Of the plague epidemics of this period, two were prepared by an unknown person in 1532 as a
devastating the Justinian plague of 541 AD and the consequence of fear of a plague epidemic although
Black Death from 1348 1351 AD. their use for health and scientific purposes did not
begin until 100 years later.7
The Black Death and Quarantine
The first public health action that can be attributed to Comprehensive analysis and interpretation was
surveillance began in 1348 AD during the bubonic introduced by John Graunt in 1662. He analyzed the
epidemic plague, infamously called as, The Black weekly bills and published in his book Natural and
Death. Quarantine measures were initiated to stop Political Observations Made upon the Bills of Mortality.
the entry of plague from outside regions. In 1348, the Graunt was the first to quantify the patterns of
public health authorities in a port near the Republic of disease and to understand that numerical data on a
Venice prevented passengers from coming ashore population could be used to study the cause of
during the time of epidemic bubonic plague in disease. He was the first to estimate the population
Europe. Quarantine as a means to control the spread of London and to count the number of deaths from
of infectious diseases was used again in 1377 in specific causes. He laid the laid the basis for the
Marseilles to detain travelers from plague infected modern use of statistics for the planning and
areas for 40 days. This was expanded in 1423 when a evaluation of public health activities.7 This early
pest house or lazaretto (houses and institutions of surveillance system illustrates the main principles of
quarantine) was constructed in Venice to hold surveillance which are still used-data collection and
detained individuals suspected of harboring analysis, interpretation to provide information, and
infections.8 dissemination of that information for action.
By the middle of the fifteenth century, the major First field investigation
cities in Europe had established permanent boards of During the industrial revolution of seventeenth
health that were responsible for identifying cases of century in Europe, London was overcrowded with
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poor sanitary conditions. The great plague of London board of health in 1848 and first public health act was
struck the city in 1665 which caused nearly 8000 passed in the same year.7
deaths. Samuel Pepys recorded the number of deaths
due to plague each day from August to November The need for more accurate and complete mortality
1665 in his personal dairy with personal revelations data in the United Kingdom led to the establishment
and eye witness reports of many events. He also of the General Register Office in 1836 and the
introduced the term, proportionate mortality, the introduction of medical certification of death and
proportion of total deaths resulting from the index universal death registration in 1837. William Farr was
disease. The epidemic of plague was ended by appointed as the first Compiler of Abstract (medical
natural interventions in 1666, by winter frost and the statistician) and created a modern surveillance
great fire of London which destroyed and cleansed System. He is recognized as the founder of modern
the overcrowded neighborhood.6 concept of surveillance.11
Legislations for surveillance In 1850, Lemuel Shattuck published Report of the
In 1741, the legislation for surveillance was first Massachusetts Sanitary Commission, in United
introduced in America, when Rhode Island passed an States. This was a landmark publication that related
act requiring tavern keepers to report contagious death, infant and maternal mortality, and
disease among their patrons. Regular reporting of communicable diseases to living conditions. In this
smallpox, yellow fever, and cholera was made an report, Shattuck proposed the creation of a
act.9 France was the first country to make health of permanent statewide public health infrastructure and
people as the responsibility of state.10 recommended establishing health offices at state
and local levels in order to gather statistical
In 1776 Johann Peter Frank advocated a more information on public health conditions.12
extensive monitoring of health in Germany that
would support public health efforts related to the John Snows study
health of schoolchildren, prevention of injuries, John Snow is regarded as the father of modern
maternal and child health, and public water and epidemiology for his work during an epidemic of
sewage disposal. Frank formulated and presented a cholera in London during 1854. John Snow mapped
coherent, comprehensive, and very detailed health cholera cases using a spot map and identified the
policy which had considerable impact both within source of outbreak as the public water pump at Broad
Germany and in countries such as Hungary, Italy, Street in London. This led to formulation of Public
Denmark and Russia that had close cultural contact health act of 1875 in England.
with Germany. This was the first link of surveillance
to health policy.10 Notification of diseases
Following the theory of contagion as a cause of
In 1834, Sir Edwin Chadwick, Secretary of the Poor disease, due to discovery of various bacteria during
Law Commission in England, conducted a Survey into the latter part of nineteenth and early part of
the sanitary Condition of the laboring classes in Great twentieth century, many countries passed laws for
Britain and was the first health administrator to periodic reporting of infectious diseases. Major
demonstrate, through surveillance, that poverty and milestones in disease notification are given in table 2.
disease were closely related. This led to poor law
amendment act in 1834 and constitution of general
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Table 2. Major milestones in disease notification
S. No Year Place Event
1 1874 United States The Massachusetts State Board of Health inaugurated a
plan for weekly voluntary reporting of prevalent diseases
by physicians
2 1888 Italy Mandatory reporting of eleven communicable diseases and
death certificates
3 1893 United Kingdom Publication of international list of causes of death by the
International Statistical Institute
4 1911 United Kingdom Use of national health insurance data for surveillance
5 1935 United States First national health survey
6 1943 Denmark First registry, the Danish cancer registry
7 1943 United Kingdom First sickness survey
8 1966 Geneva First publication of communicable disease surveillance
report by World Health Organization (WHO)
9 1967 United Kingdom Development of General Practitioners Sentinel Systems
and Netherlands
Modern concepts in surveillance:
The twentieth century saw the expansion of the In 1968, the Technical Discussions of the 21st World
concept of surveillance and the development of many Health Assembly made a full examination of
different surveillance systems. Until 1950 surveillance as an established and essential function
surveillance, meant the specific but limited function of public health practice. The concept of population
of watching contacts of certain serious diseases such surveillance was adopted and its three basic
as plague, smallpox, typhus and syphilis. The obvious characteristics were systematic collection of data;
purpose was to detect first symptoms so that prompt consolidation and analysis of the collected data; and
isolation could be instituted. It was considered as a dissemination of information by means of narrative
more ethical practice than the quarantine.11 epidemiological reports.13
The current concept of surveillance as the monitoring In 1986, Centre for Disease Control (CDC) redefined
of disease occurrence in populations was promoted public health surveillance as the ongoing systematic
by Alexander D. Langmuir in 1950. He defined collection, analysis, and interpretation of health data
surveillance as, Surveillance, when applied to a essential to the planning, implementation, and
disease, means the continued watchfulness over the evaluation of public health practice, closely
distribution and trends of incidence through the integrated with the timely dissemination of these
systematic collection, consolidation and evaluation of data to those who need to know. The final link in the
morbidity and mortality reports and other relevant surveillance chain is the application of these data to
data. Intrinsic in the concept is the regular prevention and control. CDC concept of surveillance
dissemination of the basic data and interpretations to differentiates surveillance from occasional surveys
all who have contributed and to all others who need and from planned comprehensive research
to know. He explained that the data and their programs.8
interpretations must be disseminated to all who have
contributed and to all others who need to know. But In 1988, Thacker and Berkleman defined surveillance
his definition did not include direct responsibility for as the ongoing systematic collection, analysis, and
disease control activities.10 interpretation of outcome-specific data, closely
integrated with the timely dissemination of these
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data to those responsible for preventing and The outbreak of SARS in 2003 demonstrates the
controlling disease or injury. This however contains economic impact of not having an effective global
two very different activities. Case surveillance public health surveillance system in place, with
focuses on individuals, to identify those with certain estimated income losses in the range of US$12.3
diseases and take action. Statistical surveillance, on billion to US$28.4 billion for East and Southeast Asia
the other hand, focuses on populations, to identify as a whole.16
differentials and trends that can inform public health
policymaking, including the allocation of resources.14 Uses of public health surveillance
Public health surveillance serve as an early warning
WHO in 2012 has defined Public health surveillance system in identifying new emerging health problems,
as the continuous, systematic collection, analysis and it assesses the impact and trend of new emerging
interpretation of health-related data needed for the health problems, helps in developing public health
planning, implementation, and evaluation of public interventions and allocating health resources,
health practice. evaluation of interventions, identifying risk factors
and high risk populations, and also supports public
Surveillance: the present scenario health research.17
Historically, surveillance focused on infectious
disease, then broadened to other topics, including CONCLUSION
chronic diseases, such as cancer and then diabetes. The global public health surveillance networks are
During 1980s and 1990s surveillance concepts were transforming the public health through International
applied to occupational health, environmental Health regulations (IHR) and emergence of new
health, hazard surveillance (toxic chemicals and global disease surveillance networks like FluNet18 and
physical and biological agents), emerging infectious DengueNet19 as internet sites for monitoring
diseases, injury control, behavioral risk factors, influenza and dengue information. In spite of these
events following disasters and pharmaco developments, global public health surveillance still
surveillance.15 remains unevenly distributed.
The International Health Regulations are the only At present, the boundary between global security
binding international agreements on disease control. and global public health surveillance system is
The regulations provide a framework for preventing blurred.20 Developing nations share surveillance
the international spread of disease through effective needs with the rest of the world, but they have to
national surveillance coupled with the international overcome their economic limitations along with weak
coordination of response to public health public health infrastructure, and challenges of
emergencies of global concern by using the guiding poverty and disease. So their contributions on
principle of maximum protection, minimum research are less and often depend on developed
restriction. The current regulations apply only to countries, or collaborate with them to conduct the
cholera, plague, and yellow fever; they require WHO research necessary for their surveillance needs.
member states to notify WHO of any cases of these Surveillance should be used as a scientific method for
diseases that occur in humans within their territories solving critical problems in public health practice.
and then give further notification when the territory There is an emergent need for increased international
is free of infection. Programs established to improve cooperation to address the global needs of public
the capacity of both epidemiologists and laboratories health surveillance.
to collect, use, and interpret surveillance and
outbreak data are also important components in
developing global surveillance networks.5
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