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Disease Surveillance in India. Dr Sampath K Krishnan National Professional Officer (Communicable Diseases Surveillance). Presentation. Disease surveillance NSPCD IDSP Lessons Learnt/Issues. Disease surveillance.

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Disease Surveillance in India

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Disease Surveillance in India

Dr Sampath K Krishnan

National Professional Officer (Communicable Diseases Surveillance)


Presentation

  • Disease surveillance

  • NSPCD

  • IDSP

  • Lessons Learnt/Issues


Disease surveillance

  • Disease surveillance in India has always been practiced by the states (health being a state subject)

  • Many gaps, differed in degree and quality of surveillance, different priorities in diseases

  • Rapid Response Teams (RRTs) (depending on the epidemic potential of these diseases) were called : -

    • Malaria Response Teams

    • Cholera Combat Teams

    • Other disease specific Response Teams

  • Little / no information was made available at National level


Malaria

Filariasis

Kala azar

Leprosy

TB

Polio

HIV/AIDS

VPDs

RCH

Cancer control

Blindness

Mental Health

Iodine deficiency

Water supply

Total Sanitation

National Health ProgrammesSignificant surveillance componentDisease specificToo vertical in approach Response at the district level is often delayed


Need for Surveillance

The Government of India realized the importance of Disease surveillance after the Cholera outbreak in Delhi and the Plague outbreak in Surat, which not only had significant mortality and morbidity but also significant economic consequences.


National Surveillance Programme for Communicable Diseases (NSPCD)

NSPCD was therefore launched by the Centre in 1997-98 in five pilot districts of the country (centrally sponsored scheme) and over the years extended to cover 101 Districts in the country in all 35 states and UTs in the country.


NSPCD

  • In this programme the states are the implementing agencies and NICD Delhi is the Nodal agency for coordinating the activities.

  • This programme is based on outbreak reporting (as and when outbreaks occur) with weekly reporting of epidemic prone diseases directly from Districts (including nil reporting) to the Centre.


Main strategy

To establish Early Warning System (EWS) so as to institute appropriate and timely response for prevention & control of outbreaks

  • Every state/UT and all the 101 districts has a trained multi-disciplinary Rapid Response Team

  • Rapid communications (through e-mails & fax)

  • Strengthening of state and district laboratories for rapid confirmation of diagnosis

  • Capacity development of health staff in the districts

  • IEC (information, education and communication)


Districts covered under NSPCD

1997-98 (25 districts)

1998-99 (20 districts)

2000-01(35 districts)

2001- 02 (20+1 districts*)

* The district of Shimla taken as a special case during 2002-03


Diseases/pathogens covered

  • Epidemic prone communicable diseases- acute diarrhoeal diseases including cholera, viral hepatitis, dengue, Japanese encephalitis, meningitis, measles, viral haemorrhagic fevers, leptospirosis etc.

  • Pathogens with bioterrorism potential

  • Drug resistant pathogens


Central responsibilities (NICD)

  • Development of RRT guidelines, laboratory & computer manuals, and training materials

  • Training of State Rapid Response Teams

  • Strengthening & networking of National and Regional laboratories

  • Establishing rapid communication network

  • Technical review, co-ordination, monitoring and evaluation


State responsibilities

  • Strengthening of epidemiological capabilities at state and district level by training of district RRT and health personnel at the periphery

  • Modernization and computerization of state & district Epidemiology cell

  • Strengthening of state / district laboratories

  • Improving sub-district mobility and communication

  • IEC


Expected outcome

  • Early detection of outbreaks

  • Early institution of containment measures

  • Reduction in morbidity & mortality

  • Minimize economic loss


Weekly reports received from NSPCD districts during 2001, 2002 & 2003 Jan - June


Weekly reports received from NSPCD districts during 2001,2002 & 2003 July-Dec


Monthly reports received during

2001, 2002 & 2003 from NSPCD districts


Month-wise outbreaks 2001, 2002 & 2003


Profile of outbreaks investigated by NSPCD districts


Laboratory strengthening District laboratories

WATER + STOOL C/S

WATER ONLY

NO WATER; NO STOOL C/S

NO INFORMATION

NON NSPCD DISTRICTS


Investigations performed at NSPCD district laboratories

  • Microscopy:

    • Wet mount for cholera, T/S for diphtheria, AFB smear, smear for plague bacilli, P/S for MP, P/S for Mf, BMA for LD bodies, CSF for Pyogenic meningitis.

  • Bacterial cultures & sensitivity testing:

    • Stool C/S for enteric pathogens (Salmonella, Shigella, Vibrio cholerae); Blood C/S

  • Bacteriological water testing

  • Basic serology:

    • Widal, HBV & HCV, VDRL, HIV, dengue

  • Referral of specialized serology.


Format for weekly reports

  • Week Starting

  • Week ending

  • Outbreak

    • Number

    • Nature

  • News Paper cutting

  • Report of epidemiological investigation

  • Name & Signature of Nodal Officer of District


Involvement of Medical Colleges

  • In State RRTs- Gauhati Medical College, Trivandrum Medical College, SCB Medical College Cuttack, etc

  • In District RRTs-Medical Colleges Kottayam, Khozikode, Calicut, Alappuzha, Dibrugarh, Silchar, etc

  • As Regional/District Labs- Medical Colleges Gwalior, Kolar, Bellary, Shimla, Ahmedabad, Kakinada, Silchar, Dibrugarh, etc


Monitoring of the programme

  • Review meetings- regional meetings half yearly in 2001, 2002, 2003

  • Field visits by experts throughout the year

  • Independent Appraisals carried out in 2001 and December 2003


Achievements

  • Improved quality of detection, investigation and response to outbreaks

  • Rapid Response Teams with requisite knowledge and skills in place

  • Technical material on outbreaks investigation, manual on laboratory procedures and computer usage developed and made available in field


Achievements

  • Training in computer application for data processing and communication

  • Feedback mechanism in the form of “Outbreak News” & “CD Alert” and by frequent letters through e-mail/post

  • Improved capability of laboratories for etiological diagnosis

  • Rapid transmission of information

  • NICD Website www.nicd.org (includes NSPCD networking)


NSPCD

NSPCD has significantly improved the capacity of these districts and states to detect investigate and respond to outbreaks, yet

  • It was not case based reporting and did not give a complete picture of disease burden in the country especially in respect of epidemic prone diseases

  • GoI not convinced to expand this programme to all districts in the country


Integrated Disease Surveillance Project (IDSP)

Integrated Disease Surveillance Project (IDSP) was conceptualized and proposed and the GoI approached the World Bank for the necessary funding


Objectives of IDSP

  • Establish a decentralized system of disease surveillance for timely and effective public health action

  • Improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies


IDSP

Based on case based reporting

  • Syndromic surveillance (suspect case reporting at PHC and below)

  • Confirmed case reporting of selected priority diseases (at district level)

  • Passive reporting of Road Traffic Accidents and Air Pollution.


Syndromic surveillance

  • Fever<7 days (alone, with rash, with altered sensorium/convulsions, bleeding skin/gums

  • Fever>7 days

  • Cough>3 weeks

  • AFP

  • Diarrhea

  • Jaundice

  • Unusual events causing death/hospitalization


Malaria

ADD(Cholera)

Typhoid

Tuberculosis

Measles

Polio

Plague

HIV, HBV, HCV

Unusual Syndromes

Accidents

Water Quality

Outdoor Air Quality

NCD Risk factors

State Specific Diseases

Target diseases


Project components

  • Integrating & decentralizing disease surveillance & response mechanisms

  • Strengthening Public Health Laboratories

  • Using Information Technology and Networking in disease surveillance

  • Human Resource Development


Level of responses

  • Trigger-1 : Response Health Workers

  • Trigger-2 : Outbreak Inv. & Response (PHCs/ CHCs)

  • Trigger-3 : Outbreak Inv. & Resp. (DSU)

  • Trigger-4 : Epidemic Response (SSU)

  • Trigger-5 : Disaster Response (CSU)


Project phasing

  • Phase – I (2004-05): Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh, Uttaranchal, Himachal Pradesh & Mizoram (nine states)

  • Phase – II (2005-06): Chattisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Meghalaya, Tripura, Chandigarh, Pondicherry, Delhi;

  • Phase – III (2006-07): Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland, Sikkim, A & N Island, D & N Haveli, Daman & Diu, Lakshwadeep.


Organizational Structure

Disease Surveillance Committee

Executive Committee

Disease Surveillance Unit


District Surveillance Committee

CMO

(Co. Chair)

District Program Manager

Polio, Malaria, TB, HIV - AIDS

Representative

Water Board

Chief District PH

Laboratory

Superintendent

Of Police

District Data Manager

(IDSP)

IMA

Representative

Chairperson*

District Surveillance Committee

Representative

Pollution Board

NGO

Representative

District Training Officer

(IDSP)

Medical College

Representative

if any

District Panchayat

Chairperson

District Surveillance Officer

(Member Secretary)

* District Collector or District Magistrate


STRUCTURAL FRAMEWORK

C.S.U.

S.S.U

D.S.U.

P.S.U

MED COL.

DIST HOS.

PVT. HOS.

OTHER HOS.

LABS

SUB CENTRES

PHCs/CHCs

RURAL PPs


Formats & manuals

  • Standard Case Definitions

  • Standard Formats for reporting

  • Operations manual for Health Workers, Medical Officers, Laboratory Technicians and District/State Surveillance Teams

  • Standard user friendly training manuals


NCD risk factor surveillance

  • Monitor trends of important risk factors of NCD in the community over a period of time

  • Evolve strategies for interventions of these risk factors so as to reduce the burden of diseases due to NCDs

  • Strengthen NCD surveillance at District level

  • Integrate NCD risk factor surveillance with IDSP


Strengths of IDSP

  • Functional integration of surveillance components of vertical programmes

  • Reporting of suspect, probable and confirmed cases

  • Strong IT component for data analysis

  • Trigger levels for gradated response

  • Action component in the reporting formats

  • Streamlined flow of funds to the districts


Integration

  • National programmes

  • NCDs

  • Private sector

  • Police, PCBs, Water supply

  • IEC activities

  • Training

  • Formation of committees to oversee integration


Integration ?!

  • What exactly do we expect in integration

  • Functional integration to what degree

  • Vertical programmes will continue

  • NCD component invariably stand alone

  • IEC, Training, Formats- consultation with these programmes

  • Fund sharing a daunting task


Disease Surveillance Lessons learnt / Issues


NSPCD

No budget for NSPCD nodal cell

No integration

No budget for retraining

Feedback inadequate

Weak IT component

Weak state ownership (selected districts)

Slow financial flow

Weak M & E, supervision

Weak Advocacy

IDSP

IDSP cell in Ministry with budget

Integration

Budget for retraining

Adequate feedback planned

Strong IT component

Strong state ownership (all districts)

Fast financial flow

Strong M & E, supervision

Advocacy at all levels

Lessons learnt


National Issues

  • Political considerations based on Centre-state relations

  • Central assistance proportionate to political affiliations

  • Media attention an important consideration for response

  • Time constraints-inadequate time given for outbreak investigation

  • Hesitancy for international assistance either in Outbreak Investigation or Lab support


National Issues cont’d

  • Reduced attendance in public health system and increased in private sector almost 40:60 or more

  • Wide-spread quackery in the name of alternate medicine (ayurveda, unani, homeopathy, etc)

  • ‘Overworked’ clinicians so poor maintenance of medical records like case sheets/prescription slips/provisional diagnosis/etc

  • Lack of ownership by states of central vertical programmes


State issues

  • State RRT not utilized to full potential

  • Regional labs strengthened but lab diagnosis not enhanced & increasing dependence on Centre

  • Insufficient epidemiological analysis

  • No clear IEC strategy

  • Frequent transfer/retirements of trained staff so programme invariably suffers

  • Shortage of staff so multi-tasking for state and district level functionaries.

  • Fund issues and Utilization certificates


State issues cont’d

  • Lack of competent staff especially Public Health Professionals and Microbiologists in majority of the states. Short trainings not likely to build the necessary capacity.

  • Clear demarcation between the Directorate of Health Services and Directorate of Medical Education so difficulties in integrating Medical colleges


District issues

  • Programme is focused on district epidemic preparedness and response but some districts yet to get their act together

  • Reporting from periphery needs improvement. If media first reporting then SURVEILLANCE FAILURE

  • Weekly reports incomplete and irregular (and under reporting)

  • Monthly reports also irregular (CBHI has to increase its role & responsibility)

  • Communication ‘failure’

  • CMO-CMS-DSO lack of co-ordination


District issues cont’d

  • Overworked peripheral staff to whom all programmes are dependent on

  • Multiple formats for different programmes

  • Rapid Response Teams usually composed of specialists from District hospital/ Medical college and problem in rapid mobilization as from different agencies

  • Concept of Nil reporting/routine reporting difficult for the peripheral staff to understand, compounded by lack of feedback from the higher levels


District lab issues

  • District labs few established and functioning satisfactorily

  • Many labs in a district:

    • Public health lab-testing water samples

    • Hospital lab-testing for NCDs and clinical requirements

    • Medical College lab-testing for majority of the diseases

    • Surveillance lab-testing for few diseases

    • District blood bank –with ELISA reader

    • Peripheral labs-Microscopy only

      Co-ordination between these labs so that overall district lab capacity enhanced


Thank You


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