Research Agenda in Public Health Surveillance
Developing nations share surveillance needs with the rest of the world, yet they are challenged by economic limitations, weak public health infrastructure, and the overwhelming challenges of poverty and disease. As a result, countries in the developing world often depend on the research efforts of others, or they collaborate with others to conduct the research necessary for their surveillance needs. Within individual countries, surveillance systems are essential in measuring disease and injury burden as a first step in establishing public health priorities that lead to policies and programs.
The major research question for surveillance is how to develop and maintain a cadre of competent, motivated surveillance and response workers in developing countries. Other questions include how to design and maintain surveillance systems for these problems, especially morbidity systems for chronic diseases. Standard methods can be used to evaluate existing surveillance systems, which, in turn, will help define surveillance needs (Romaguera, German, and Klaucke 2000). Developing countries have used the IDSR strategy, which provides an efficient approach to data collection and analysis. Unfortunately, the majority of developing countries have limited surveillance systems for noninfectious diseases; instead, existing data systems (for example, vital records, motor vehicle crash records, or insurance claims data) are potential sources of surveillance data. In other settings, even these data sources are scarce, and approaches such as verbal autopsies and recurrent surveys might be alternatives (White and McDonnell 2000).
Surveillance for risk factors is another challenge, and BRFSSs need to be validated and applied more widely in developing countries. Surveillance for injuries, environmental hazards (such as traffic intersections that are associated with high rates of injuries), and exposures to chemical or biological agents is a key public health concern with few examples of effective application anywhere in the developed or less developed parts of the world. Rigorous research is required in this field (Thacker and others 1996).
The burgeoning use of electronic data systems and the almost universal availability of the Internet provide a tremendous opportunity for more timely and comprehensive surveillance in all parts of the world. Yet in this rapidly emerging field, critical needs exist, including the following:
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competent, motivated health workers
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data standards (Lober, Trigg, and Karras 2004)
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global policies and practices for international surveillance
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useful software (Dean 2000)
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evaluation of the effectiveness of all these applications.
New approaches that must be evaluated by using standard methods (Romaguera, German, and Klaucke 2000) include the following:
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IDSR for infectious diseases
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syndromic surveillance (CDC 2004b) for terrorism and emergency response
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laboratory-based surveillance methods to enhance diagnostic accuracy and increase timeliness of recognition of outbreaks and interventions (Swaminathan and others 2001).
Many research questions remain about surveillance methodology, including how to do the following:
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use data for forecasting or temporal and spatial analysis for aberration detection
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conduct surveillance for multiple competing risk factors that lead to a single condition (for example, smoking, cholesterol, hypertension, and overweight for heart disease)
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conduct surveillance for the adverse effects of drugs
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interpret ecologic data relative to data collected on individuals (Greenland 2004)
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measure cost-effectiveness of alternative approaches to surveillance (for example, integrated compared with categorical approaches)
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link data sources effectively (for example, hazard, exposure, and outcome data for environmental diseases)
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build and sustain human infrastructure in developing countries
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strengthen evidence-based decision-making cultures in ministries of health and finance.
