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Disease Surveillance in India

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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  1. Disease Surveillance in India Dr Sampath K Krishnan National Professional Officer (Communicable Diseases Surveillance)

  2. Presentation • Disease surveillance • NSPCD • IDSP • Lessons Learnt/Issues

  3. 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

  4. 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

  5. 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.

  6. 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.

  7. 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.

  8. 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)

  9. 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

  10. 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

  11. 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

  12. 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

  13. Expected outcome • Early detection of outbreaks • Early institution of containment measures • Reduction in morbidity & mortality • Minimize economic loss

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

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

  16. Monthly reports received during 2001, 2002 & 2003 from NSPCD districts

  17. Month-wise outbreaks 2001, 2002 & 2003

  18. Profile of outbreaks investigated by NSPCD districts

  19. Laboratory strengthening District laboratories WATER + STOOL C/S WATER ONLY NO WATER; NO STOOL C/S NO INFORMATION NON NSPCD DISTRICTS

  20. 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.

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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)

  26. 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

  27. 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

  28. 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

  29. 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.

  30. 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

  31. 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

  32. Project components • Integrating & decentralizing disease surveillance & response mechanisms • Strengthening Public Health Laboratories • Using Information Technology and Networking in disease surveillance • Human Resource Development

  33. 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)

  34. 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.

  35. Organizational Structure Disease Surveillance Committee Executive Committee Disease Surveillance Unit

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. Integration • National programmes • NCDs • Private sector • Police, PCBs, Water supply • IEC activities • Training • Formation of committees to oversee integration

  42. 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

  43. Disease Surveillance Lessons learnt / Issues

  44. 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

  45. 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

  46. 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

  47. 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

  48. 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

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