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Epidemiological surveillance:
dynamic and long-term process
J.L. Castanheira, C. Gomes and J. Catarino, Department of Epidemiology
and Health Statistics, General Directorate of Health, Portugal
P
ortugal is a Member State under modest development in
the context of Organisation for Economic Co-operation
and Development (OECD) – in 2007, gross domestic
product per capita was EUR15,373.
1
The country is provided
with a preparedness plan which seems to be adequate. Work
undertaken in preparation for the anticipated pandemic has
included the elaboration of a contingency plan developed in the
following four axes:
• Epidemiological surveillance
• Prevention/control measures
• Communication
• Evaluation.
The most recent version of the Portuguese National Pandemic Plan
2
(March 2007) follows World Health Organization (WHO) guide-
lines, protocols, strategies and influenza activity periods and phases.
The plan has received wide social recognition, and has been posi-
tively recognized by national and international entities. As
epidemiologists, we believe this is due to the following:
• Because it is oriented towards action based on epidemiological
evidence, the conceptual framework adopted is the most adequate
• Procedures are aimed at assuring a social dynamic appropriate
for controlling situations and solving problems. Thus, from plan-
ning to evaluation, procedures are anchored in and facilitate the
sustained, active and engaged participation of stakeholders
• The plan is rooted in an equitable and universal public health
structure and is well articulated, from the frontline to rehabilita-
tion, with the health care provision network.
Nevertheless, these features are not fortuitous; they are the result of
favourable conditions (cultural, social and geographic) and of the
natural evolution of policies aiming to control communicable
diseases. We are proud of such policies, which have been systemat-
ically adapted since the nineteenth century and have been formatted
according to an epidemiological surveillance system that has been
in place for decades.
Main features
Portugal is a country of about 10.5 million inhabitants, with an area
of 92,000 km
2
– three times the size of Belgium and almost a sixth
of France. Portugal has been independent and unified country since
the twelfth century, and has maintained its present borders for more
than 700 years. An important colonial power since the sixteenth
century, Portugal did not enjoy in any significant way the socio-
economic impact of the nineteenth century’s Industrial
Revolution.
The recent history of public health in Portugal can be
divided in three time periods: before 1971 (the sanitary
period), between 1971 and 1979 (the ‘health centre’
period), and after 1979 (the post-NHS period).
3
The network of health authorities was initiated during
the nineteenth century based on about 300 municipali-
ties. In 1898 it was enriched with a National Laboratory
of Public Health, later nominated Instituto Nacional de
Saúde Dr Ricardo Jorge. At local level, public health
services performed both environmental and personal activ-
ities. These focused mainly on preventive programmes
(such as immunization), care of specific health risk groups
(for example, maternal and child health), and the control
of endemics (such as tuberculosis).
In 1971, relevant legislation paved the way for changes
in Portuguese public health, with the implementation of
an extensive network of health centres and a career struc-
ture for health professionals, including a well-defined
medical public health career. In fact, the Portuguese
health centre experience pioneered the concept of health
care systems based on primary health care.
Since 1979, the implementation and development of
the National Health Service (NHS) have been influenced
by different prevailing political models and management
capabilities. It seems apparent that the Portuguese NHS
brought about public health without a highly visible
public health service, a consequence of the integrative
logic adopted. Since then a key challenge and a critical
issue has been how to foster a coherent public health
philosophy, explicit public health policies, significant
health promotion actions, and a steady development of
public health training and research in the absence of a
specific public health structure. However, private prac-
tice was never limited, and in order to face a health crisis
or health management problems, efforts are likely to be
seen that aim to involve all hospitals and ambulatory
health care units, in public and private sectors. Nowadays,
the NHS includes 21,024 medical doctors and 36,812
nurses, with 35 per cent of doctors and 23 per cent of
registered nurses integrated in primary health care units.
4
Epidemiological surveillance has been facilitated
through mandatory notification of communicable