Surveillance system in Saudi Arabia

Health surveillance programs in Saudi Arabia are as old as the Kingdom itself, beginning in 1933 (1353 Hejira) with a Royal decree implementing communicable disease prevention efforts. In 1940, Aramco began malaria control activities, particularly in the Eastern Region, to protect its employees from major endemic health problems. Taking seriously its responsibility as the site of Islam's two holiest cities, the government in 1952 began its own malaria control efforts to protect pilgrims on their route to Makkah and Madinah. This program was later expanded to include all malarious areas of the Kingdom. In 1963, the government and the World Health Organization agreed on a plan of operation along the lines of the worldwide malaria control program. In 1979, the first comprehensive annual report of communicable diseases was published by the Department of Preventive Medicine, Ministry of Health, and over the years the surveillance system has been expanded.

The objectives of the surveillance system are:

The surveillance system functions on several levels. The primary health care centers (PHCCs) collect morbidity data for reportable diseases and compare that data with previous information in order to detect any change, either up or down. They pass that information on to the regional level for action, and work with patients and their contacts in instituting preventive measures.

At the regional level, surveillance data from the PHCCs are analyzed and the diagnosis and preventive measures are verified. These data are passed on to the central authority for action. The data are compared with other regional and national figures. Regional health authorities also provide technical and educational support for employees.

Finally, the central level collects, tabulates and presents all regional data. Regional and national incidence rates are compared with each other and with international figures. The central authority verifies reasons for trends as described by local and regional levels and provides technical support as needed, either by personal visit or by phone and fax. Finally, it ensures that preventive and control measures are within stated policy and decides whether changes in policy are needed.

Surveillance is conducted in several ways. Most information comes from passive surveillance, whereby the central authority collects information sent in by the regions. Reporting times are established by law. Diseases are reportable by number and classified by week of occurrence, age group, nationality and sex. Animal bites and scorpion stings are reported every one and three months, respectively. Active surveillance is used in certain circumstances when completeness is important. Recent examples include collection of information about Haemophilus influenza and some zoonotic diseases, such as brucellosis.

Sentinal reporting comes from selected institutions that provide rapid information on common diseases; measles, for instance, is reported on a weekly basis and meningitis on a daily basis. Laboratory-based surveillance is currently carried out only for poliomyelitis and animal rabies.

Case investigation reports include getting information on contacts of patients, observing those contacts for the maximum incubation period, collecting relevant specimens for laboratory examination, providing chemoprophylaxis, and determining the source of infection and mode of transmission. Occasionally, special surveys are conducted to collect information that may not be available by routine reporting.

The notifiable communicable diseases are divided into two categories (above). Class 1 diseases, epidemics and any unusual occurrence of events must be reported within 24 hours. Class 2 diseases are reported weekly from PHCCs to regions and monthly from regions to the central authority.

A surveillance system is useful if it contributes to the prevention and control of disease. For example, the Expanded Program on Immunization concentrates on vaccinating children under age 2 against childhood diseases. Analysis of surveillance data noted a high incidence of measles in children aged 5-14. This led to the requirement that all children be vaccinated prior to school enrollment and that the first dose of measles vaccine be given at 6 months of age. A high mortality rate due to scorpion stings led to a fivefold increase in the dosage of the antitoxin. Veterinary authorities were convinced to implement an animal immunization program by the high incidence rate of brucellosis.

The system is reviewed regularly for completeness, timeliness, accuracy and flexibility. Feedback throughout the surveillance system is crucial and is accomplished by phone, fax, regular visits, letters and publications such as this one.

The MOH is pledged to improve the surveillance system. We plan to strengthen and upgrade the central computer system and extend it to regional and local levels. A communicable disease manual is being prepared. Finally, training in epidemiological surveillance will be expanded.