to Community Medicine Course 31505201 Public Health Surveillance By Hatim Jaber MD MPH JBCM PhD 11 12 2017 1 Number of people affected by dementia to triple ID: 777447
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Faculty of Medicine Introduction to Community Medicine Course (31505201) Public Health Surveillance
By Hatim JaberMD MPH JBCM PhD11- 12- 2017
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Slide2Number of people affected by dementia to triple in next 30 years2
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Slide44
Slide5Post midtermWeek 8 Unit 6: Demography and DataWeek 9 Midterm assessment (Exams.)15-11-2017Week 10 Unit 8 Introduction to Epidemiology.Week 11 Unit 9: Prevention and Control of Diseases
Causation Week 12 Unit 10: Communication and Health Education Week 13 Unit 11
: Public Health Surveillance and ScreeningWeek 14
Unit 12: Health Administration and healthcare
management
Week 15 Unit 13: Revision and
Health Research
Week 16
Final assessment (Exams.)
4-1-2018
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Slide6Presentation outlineTimeDefinitions of surveillance08:00 to 08:15Objectives of surveillancePublic health vs health care surveillance
08:15 to 08:30Elements of a surveillance system08:30 to 08:45Surveillance methods08:45 to 09:00
Surveillance system in Jordan
09:00 to 09:15
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Slide7Data Sources: PopulationCensusVital registration systemSample household surveysSpecial population surveysDemographic (elderly, youth)Risk groups ( IDUs)Occupational (farmer, skilled labor)Area-based (catastrophe-affected)
Biomarkers7
Slide8Types of InformationSurveillance EpidemiologicalBehavioralRoutine service reporting Special program reporting systemsAdministrative systemsVital registration systemsFacility surveys
Household surveysCensusesResearch and special studies8
Slide9“Surveillance”9
Slide10The word "sur-veillance" means (in French) "to watch from above" ("veiller" = "to watch" and "sur
" = above") (i.e. a God's-eye view looking down from on-high) The term is often used for
all forms of observation,
not just visual observation.
The word
“Surveillance”
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Slide1111Public health surveillance (sometimes called epidemiological surveillance) is :the ongoing systematic collection, analysis, and interpretation
of outcome-specific data essential to the planning, implementation, and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know. Outcomes may include
diseases, injury, and disability, as well as risk factors, vector exposures, environmental hazards, or other exposures. The final link of surveillance chain is the
application
of these data to
prevent and control
human diseases and injury
.
Definition of
Surveillance
Slide12Surveillance is: “Information for Action” “If you don't use it, then do not ask for it!”However: “Good surveillance
does not necessarily ensure the making of the right decisions, but it reduces the chances of the wrong ones” A. D. Langmuir (1963)
Surveillance Principle
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Slide1313In 1950, the term “surveillance” was restricted to public health practice to watching contacts of serious communicable diseases”To early detect symptomsTo institute prompt treatmentExample: SmallpoxHistory
Slide14Surveillance is systematic ongoing collection, collation, and analysis of data, and the timely dissemination of information to those who need to know so that action can be takenA survey is a one data collection episodeRegistries are not
for immediate actionHealth Management Information Systems (HMIS) for annual reports
Surveillance, surveys, registries and HMIS:14
Slide15Who PerformsPublic Health Surveillance?
Epidemiologists
Medical professionals (doctors, nurses, clinics)
Pharmacies
Health insurance providers
Emergency
responders
Public health departments (local, state, federal)
Surveillance
provides the information for descriptive epidemiology
, which is
Person (age, sex, description)
Place (where)
Time (dates, hours, days, months, years)
What is Public Health Surveillance? -Continued
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Slide1616Registers are archival health informationSurveillance is dynamic as compared with surveys: Interplay between epidemiologic studies and control activitiesSurveillance is not mere:ReportingMonitoringData collection
Note the Differences:
Slide17Continuous versus Periodic Data Collection
Continuous Data Collection
Periodic
Collection
Data Collection
Small team
Large team or multiple teams
Data accessibility
Initially slow
Faster turnaround
Data usefulness for trend analysis
Ongoing results
Results only after three rounds of data collection
Evaluation of health intervention
Continuous monitoring of impact
Timing of collection often not linked to intervention
Budget
Line item in health budget
One-off investment at each cycle
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Slide1818Public health vs health care surveillancePublic healthprotection, promotion, and restoration of health of population includes health care services, especially if publicly-funded Health careservices provided to individuals or communities by agents of health services or professionals to promote, maintain, monitor, or restore health. Not
limited to medical care (therapy by MD)
Slide1919Public health vs health care surveillance (cont’d)Health care surveillance may be part of public health surveillance (e.g., Montreal DSP)also conducted by other agencies and/or health care organizations (e.g., hospitals)Population may differpublic health: usually defined geographically (district, region, country)
health care: recipients of services or catchment population
Slide2020Detect outbreaks or epidemicsDetect changes in trends over time, portray natural history of diseasesEvaluate control measuresEstimate magnitude of morbidity and mortalityEnsure equity in health care (mortality and morbidity)Facilitate planning Making projections, understanding burden of disease and justifying allocation and or redirection of resources
Stimulate epidemiologic researchGenerate/ Test hypotheses (e.g. changes in health practice)Identify risk factors (in-depth studies)
Goals and Uses of Surveillance
Slide21Early detection and prediction of outbreaksDescription of the magnitude of disease
Understanding risk factors for diseasesMonitoring trends of e
ndemic disease
Monitor programme
performance and progress
towards a control
objective
Estimate future disease impact
Objectives
of Surveillance
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Slide22Surveillance objectives
Surveillance
should be
SMART
...
S -
S
pecific
(regarding event which is subject of )
M -
M
easurable
(gain info for comparison )
A -
A
ction oriented
(information for action)
R -
R
ealistic &
(feasible in time and place)
T -
T
imely (
action implemented in time to be effective)
Setting objectives – balance between requirements and interests!
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Slide2323High-quality surveillance increases credibility of public health care providers:Encourages transparencyReduces over-reactionAttract donorsEncourages implementation of new interventions; new conjugate meningococcal vaccinesFacilitates better management of disease control and other public health programs
SAVES LIVES !!!!Added values of Surveillance
Slide2424Importance of Good Reporting
Health Care SystemPublic Health Authority
Event
Data
Information
Intervention
Reporting
Feedback
Analysis & Interpretation
Evaluation
Slide2525
Early warning indicators:Count of cases (?)Attack rates (stratified)Case-fatality rates
Temporal componentDefined thresholds
Notification of cases
Suspect and probable
Case-
based
data
Immediate or weekly
Early Detection…
Delayed Detection Means
=Delayed
Response
Slide26Where Do We Get Public Health Surveillance Data?
Vital records
Hospital records, death certificates, birth records
Surveys
Schools, doctors, insurance companies
Environmental monitoring systems
Water or air quality
Animal health data
Veterinarians, farms, food manufacturing
Where Do We Get Public Health Surveillance Data?
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Slide2727Types of SurveillanceActive vs. Passive SurveillanceActive Surveillance:
Health department solicits reportsPassive Surveillance: Reports are initiated by source for data
Slide28Passive surveillance; Routine surveillance where reports are awaited and no attempt make actively seek reports from the participants in the system.
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Slide29Routine and sentinel surveillanceSentinel surveillance; The surveillance of a specified health event in only sample of the population at risk using a sample of possible reporting sites. The sample should be representative of the total population at risk.
Passive surveillance; Routine surveillance where reports are awaited and no attempt make actively seek reports from the participants in the system.
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Slide3030Often provides an early alert for outbreaks Most useful for diseases that occur frequently Not intended to capture all casesFocal points: Clinics, hospitals or laboratories Strategic locations
Representative to population (socio-demographic) High risk groupsLess sites but better quality of databring attention to problems in practices, procedures or systems Useful for research activities
Sentinel Surveillance
Slide31Aggregate surveillance; The surveillance of a disease or health event by collecting summary data on groups of cases (e.g. in many general practice surveillance schemes clinicians are asked to report the number of cases of a specified diseases seen over a period of time).
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Slide32Case-based surveillance; The surveillance of a disease by collecting specific data on each case (e.g. collecting details on each case of Acute Flaccid Paralysis in polio surveillance) Cluster;
The occurrence of an unusual number of cases in person, place
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Slide33Community surveillance; Surveillance where the starting point is a health event occurring in the community and reported by a community worker or actively sought by investigators. This may be particularly useful during an outbreak and where syndromic case definitions can be used.
Comprehensive surveillance; The surveillance of a specified disease or health event in the whole population at risk for that event.
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Slide34Enhanced surveillance; The collection of additional data on cases reported under routine surveillance. The routine surveillance is a starting point for more specific data collection on a given health event. This information may be sought from the reporter, the case, the laboratory or from another surveillance data set.
Intensified surveillance; The upgrading from a passive to an active surveillance system for a specified reason and period (usually because of an outbreak). It must be noted that the system becomes more sensitive and secular trends may need to be interpreted carefully.
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Slide35Syndromic SurveillanceSyndrome is a complex of symptomsSyndrome is constellation of signs and symptoms!Syndromic surveillance focuses on one symptom or constellation of symptoms (clinical outcomes) rather than a diagnosed disease
No need of laboratory confirmation. Hence fast.More sensitive, but less specificFaster public health interventionsFor Example – WHO ALERT system for early detection of outbreaks is syndromic
S.SS is surveillance for AFP (syndrome, clinical outcomes
) in order to capture possible cases of poliomyelitis.
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Slide3636Surveillance of Disease vs. PersonsSurveillance of Disease:“ The continuing scrutiny of all aspects of occurrence and spread of disease that are pertinent to its effective control”Surveillance of Persons
:“ The continuing scrutiny of disease contacts, high risk groups in order to promote prompt recognition of infection or illness”
Slide3737Elements of a surveillance systemCase definitionIndicatorsPopulation under surveillanceCycle of surveillanceConfidentialityIncentives to participation
Slide38Case definition; A set of diagnostic criteria that must be fulfilled to be regarded as a case of a particular disease. Case definitions can be based on clinical criteria, laboratory criteria or a combination of the two.A case definition is a set of criteria that triggers reporting
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Slide3939Elements of surveillance system:case definitionRequirementsIndicator (not diagnostic) of trendsSimpleFeasibleReliableInexpensiveExamplesMeasles: fever with red rash, red eyes, disappearing within a weekCholera: Sudden and severe watery diarrhoea, with rapid and massive dehydrationMalaria: Fever, rigors, headache, body aches, inability to carry out normal daily activities
Slide40Case definitionYES- A “case” is an event
- An event is something that happens to:A person, In a given place, At a given time
- A case definition is a set of criteria that triggers reporting
NO
- A “case” is
not a person
- Events do not exist if you lack info:
On the person
On the place
On the onset date
-
A case definition is
not a diagnosis made to decide treatment
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Slide41Case definition Includes:Time, place, person.
Clinical featuresand /or Laboratory resultsand/or Epidemiological features
Should be:
Clear, simple
Field tested
Stable and valid
Adopted
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Slide42Case definition--three-level definitionsMeningococcal disease (SURVEILLANCE PURPOSES)Possible caseClinical diagnosis
of meningitis or septicaemia or other invasive disease where the consultation with the clinician and microbiologist, considers that diagnoses other than meningococcal disease are at least as likelyProbable caseClinical diagnosis of meningitis or septicaemia or other invasive disease where the consultation with the physician and microbiologist, considers that meningococcal infection is the
most likely diagnosis
Confirmed case
Clinical diagnosis of meningitis, septicaemia or other invasive disease
AND at
least one of:
Neisseria
meningitidis
isolated from normally sterile site
Gram negative
diplococci
in normally sterile site
Meningococcal DNA in normally sterile site
Meningococcal antigen in blood, CSF or urine.
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Slide4343Elements of surveillance system:population under surveillancePopulation-basedInstitution-basedhospitals, practices, nursing homes, prisons, schools Combinationse.g., Drug Abuse Warning Network (DAWN) in US: morbidity and mortality data on illicit drug use from hospital ERs and medical examiners/coroners
Slide4444Elements of surveillance system:cycle of surveillanceOccurrence of health eventDetection by health care providerNotification of health agencyAnalysis and interpretationDissemination
Slide4545Elements of surveillance system:confidentialityLegally mandated reporting requires confidentiality precautionslimited access to data (locks, passwords etc)encryption algorithms for coding namesPerceived lack of confidentiality a major deterrent to completeness of reportingSTDsdrug use
Slide4646Surveillance methodsActive vs passive methodsLegally notifiable diseasesSentinel eventsSentinel surveillanceCross-sectional vs longitudinal
Slide4747Surveillance methods:longitudinal vs cross-sectionalLongitudinalOngoing data collectionIncident casesExamples: notifiable diseases, vital statistics, disease registriesCross-sectionalSerial surveys
Slide4848National:Periphery: (e.g., PHCC catchment area, city)Intermediate: ProvincialCentralInternational:International Health Regulations 2005
Levels of Surveillance
Slide4949Natural and man-made disasters (emergencies)During Special events of mass gatherings (Pilgrims to MakkahOlympicsLaboratory-based surveillance: Emerging pathogensAntimicrobial resistanceInfection controlBehavioural risk factors
OthersSpecial Surveillance Programs
Slide5050Systems of Disease SurveillanceNotifiable disease reporting systemsLaboratory-based surveillanceHospital-based surveillancePopulation-based surveillanceVital records (birth and death certificates)
Registries
Slide51DEFINITIONSDisease notification is a process of reporting the occurrence of disease or other health-related conditions to appropriate and designated authorities.A notifiable disease is any disease that is required by law to be reported to government authorities. 51
Slide52A notifiable disease is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the prevention and control of the disease.Physicians are required by law to report cases of certain infectious diseases. Unfortunately, many do not.52
Slide53Surveillance DefinitionsActive case-finding; The
dynamic identification of the occurrence of a disease or health event under surveillance. (e.g. house visits by community workers to identify cases of tuberculosis).
Active surveillance;
Routine surveillance where reports are
sought dynamically from participants
in the surveillance system on a regular basis (e.g. t
elephoning
each participant monthly to ask about new cases
).
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Slide54Surveillance sensitivity; The ability of a surveillance system to detect an outbreak. (The proportion of all outbreaks that could have been detected by the system).Surveillance predictive value
; The likelihood that an “outbreak” detected by a surveillance system is truly an outbreak
54
Slide55Survey; An investigation in which information is systematically collected. It is usually carried out in a sample of a defined population group and in a defined time period. Unlike surveillance it is not ongoing though it may be repeated. If repeated regularly surveys can form the basis of a surveillance system.
Zero reporting; The reporting of zero cases when no cases have been detected by the participant.This allows the next level of the system to be sure that the participant has not sent data that has been lost or has forgotten to report.
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Slide56The following should be addressed for each disease under surveillance:is the
case definition:- clear? appropriate? consistent throughout the surveillance system?is the reporting mechanism:
clear ? efficient?
of appropriate reporting periodicity? available to all relevant persons and institutions
?
is
the analysis of
data
: appropriate
? susceptible to proper presentation? used for decision-making?
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Slide57do the personnel involved: have a good understanding of the value of the surveillance system? understand, show interest in, and support, their own surveillance task? have enough appropriate human and material resources?do the personnel involved receive appropriate: training? supervision?is the
feed-back from intermediate and central levels: appropriate? sufficient? motivating?When the assessment of current activities is done, the next question is:· Is there an operational control program for each of the priority diseases?
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Slide5858Reporting Channels
Slide59CHAIN OF REPORTING HCP DNO LG MOH WHO/CDC FMOH SMOHKey:HCP: Health care providersDNO: Disease notification officerLG MOH: Local Government Medical Officer of HealthSMOH: State Ministry of HealthFMOH: Federal Ministry of Health
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Slide6060NotificationA notification is the reporting of certain diseases or other health-related conditions by a specific group, as specified by law, regulation, or agreement. Notifications are typically made to the state or local health agency.
Slide61Integrated Disease Surveillance and Response (IDSR)IDSR form 001: For immediate/case based reporting of diseases.Immediate reporting allows for timely action to be taken to prevent the re-emergence or rapid transmission of epidemic prone diseases or events, especially diseases due to highly pathogenic and lethal infectious.61
Slide62Diseases/Events reported with form IDSR 001 list of diseases/events requiring immediate reporting.Acute Flaccid Paralysis (AFP)Acute hemorrhagic fever syndrome(Ebola, Marburg, Lassa Fever, RVF,Crimean-Congo)Adverse event following immunization(AEFI)AnthraxChikungunyaCholeraCluster of SARIDiarrhoea with blood (Shigella)Dracunculiasis
Influenza due to new subtypeMaternal deathMeaslesMeningococcal meningitisNeonatal tetanusPlagueRabies (confirmed cases)SARSSmallpoxTyphoid feverYellow feverAny public health event of internationalconcern (infectious, zoonotic, food borne,
chemical, radio nuclear or due to anunknown condition)
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Slide63IDSR form 002: For weekly reporting of new cases of epidemic/pandemic prone diseases.IDSR form 003: For routine monthly notification of other diseases of public health importance.Integrated Disease Surveillance and Response (IDSR)63
Slide64Diseases that require monthly reportingAcute viral hepatitisAIDS (New Cases)Buruli ulcerDiabetes mellitusDiarrhoea with severe dehydration in children under 5 years of ageHIV (new detections)HypertensionInfluenza-like illnessInjuries (Road Traffic Accidents)Leprosy (quarterly)Lymphatic FilariasisMalariaMalnutrition in children under 5 yearsMental health (Epilepsy)Noma
OnchocerciasisSevere pneumonia in children under 5years of ageSexually transmitted diseases (STIs)TrachomaTrypanosomiasisTuberculosis (quarterly)Underweight Newborns (less than 2500 g)
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Slide6565Vary from one country to another Differences within countries Changes over timeAdding one single disease to the list could cost a lot: Money, time, avoidable confusionVariables collected should be indicators of potential or arising problems rather than identifying risk factorsReport only confirmed cases?
Reportable Diseases
Slide6666Weekly? Appropriate most timesMonthly? Less sensitive Quarterly? At national level Daily? Daily reporting could be cumbersome Daily reporting may be required during emergencies, disasters Avoid inconsistencies in case
definitions Reporting suspected vs. confirmed casesFrequency of Reporting Diseases
Slide6767Should be (for line-listing): Simple Minimum content Layout easy to understand Easy to reproduceSpecial data collection forms:Special surveillance programs (e.g., Malaria, vector control) During outbreaks (Locally acquired or imported?) Eradication activities
Data Collection Forms
Slide6868Public Health LaboratoriesFully linked to epidemiological surveillanceAbility to confirm diagnosis of epidemic – prone diseases of national interestMonitor and report selected pathogensMeningococcal meningitis and other bacterial meningitisCholera, Shigellosis and salmonellosisViral Hemorrhagic fevers, etc
Monitor antimicrobial resistance
Slide69Summaries,
Interpretations,
Recommendations
Reports
Health
Agencies
Health Care
Providers
Public
Analysis
Information
Loop
of Public Health Surveillance
69
Slide70Essential activities of surveillanceIdentify; define and measure the health problem of interest; Collect and compile data about the problem (and if possible, factors that influence it)Analyze and interpret these data
Provide these data and their interpretation to those responsible for controlling the health problem andMonitor and periodically evaluate the usefulness and quality of surveillance to improve it for future use.
N.Bsurveillance of a problem
does
not
include actions to control the problem.
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Slide7171Absolute numbersProportionsRatesPercentagesThresholdKey Indicators
Slide7272Information Management
Slide7373Evaluation of Surveillance Systems
Slide7474To improve existing surveillance systemsTo modify systems because of changes in Priorities Epidemiology DiagnosticsTo optimize the use of available resources
Goals of Evaluation of Surveillance
Slide7575International Health Regulations 2005Current: Notification to WHO of a case of cholera, plague or yellow feverIHR 2005Public health emergencies of international importanceObligation to establish core capacities Assistance to StatesContext specific & flexible recommended measuresExternal advice (emergency and review committees) regarding IHR
Slide76National Notifiable Disease SurveillanceReporting mandated by state law/regulationHealth care providers, laboratories report to local HD (county)County HD submits reports to StateReports transmitted to CDC primarily through National Electronic Telecommunications System for Surveillance (NETSS)
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Slide77Map of 54 clinics that participated in the public health surveillance project between May – December 2014 (indicated by red dots)77
Slide7878Mortality surveillance
Slide7979Influenza: laboratory surveillance
Slide80YearReported Cases (Thousands)
Vaccine licensed
0
50
100
150
200
250
300
350
400
450
500
1963
1968
1973
1978
1983
1988
1993
1998
MEASLES — by year, United States, 1983–1998
0
5
10
15
20
25
30
Year
1983
1988
1993
1998
Reported Cases (Thousands)
Evaluate control measures of MEASLES
United States, 1963-1998
20
10
80
Slide81Table of diseases, conditions and events reported in the public health surveillance project81
Slide82Table of diseases, conditions and events reported in the public health surveillance project82
Slide83Proportional morbidity of reported communicable disease cases, excluding acute diarrhoea and chicken pox, through the public health surveillance system between May – December 201483
Slide8484
Slide85Figure 5.7 Reported Cases of Salmonellosis per
100,000 Population, By
Year
—
United States, 1972
–
2002
S
ource:
Centers for Disease Control and Prevention. Summary of notifiable diseases
–
United States, 2002. Published April 30, 2004, for MMWR 2002;51(No. 53): p. 59.
Total number of AIDS cases includes all cases reported to CDC as of December 31, 2002. Total includes cases among residents in the U.S. territories and 94 cases among persons with unknown state of residence.
Source:
Centers for Disease Conrol and Prevention. Summary of notifiable diseases
–
United States, 2002. Published April 30, 2004, for MMWR 2002;51(No. 53): p.
59.
Figure 5.8 Reported Cases of AIDS, by Year
—
United States* and U.S. Territories, 1982
–
2002
85
Slide86Measles/rubella incidence in Macedonia and immunization schedule changes in the period 1967-1997 86
Slide87Remember….Surveillance is information for action!87