Framework for implementation of revised IHR 2005 in India

1. World Health Organization Country Office - India Framework for implementation of revised IHR 2005 in India Dr Sampath K Krishnan Coordinator CDS & IHR Contact Point

2. World Health Organization Country Office - India Presentation • Health Legislation & Governance • Disease surveillance • NSPCD • IDSP • Plan of action for implementation of IHR in India

3. World Health Organization Country Office - India Constitutional allocation of Government powers • Federal structure - Health is a state subject in the main • Central (Union) list, State list & Concurrent list • Central list has more of public health legislations whereas state list also has legislations for health emergencies • Concurrent list also contains important areas concerning public health which can be taken up by state or centre. • Pandemic diseases could be declared as Public health disasters and centre could take control-e.g. SARS, Avian Flu, Pandemic Flu

4. World Health Organization Country Office - India Constitutional protections • Constitution of India guarantees right to life (Article 21). Right to health as a pre-requisite recognized by the Supreme Court. • Under Directive Principles of the State, health care is the responsibility of the State (Nation) • Public health can override individual rights • E.g. in Avian influenza-social isolation and limited quarantine were introduced in affected areas • Poultry farmers supported culling operations. • Protests could occur even if legislations are in place

5. World Health Organization Country Office - India Constitutional procedural requirements • Enactments/ amendments would be required for effective implementation of IHR • But presently, could be implemented under existing health/other legislations (even though some are quite old) • Other legislations also may be used when necessary • E.g. Criminal Procedure Code (CrPC) in MP and Police Act in Maharashtra imposed during avian influenza outbreak (under maintenance of public law and order)

6. World Health Organization Country Office - India Federal system • Health is a state subject in the main hence states usually enact their own health legislations • States usually have their own surveillance systems in place. Were earlier reporting on a monthly basis to Central Bureau of Health Intelligence for about 30 diseases of PH importance • NSPCD programme ensured that the 101 districts in these states reported outbreaks directly to Centre (NICD) • States sometimes report late to Centre due to various reasons including awaiting lab confirmation of diagnosis • States obtain significant funding from centre for • All sub-centres • PHC/CHC- Temporary staff, drugs, lab equipment • Anganwadis –ICDS (creche)

7. World Health Organization Country Office - India Role of centre in control of important diseases of public health importance • Detailing of central teams for assisting investigation and response • Capacity building and laboratory support • Project mode-IDSP, NACP, RNTCP, NPSP. These then become National Health Programmes (may have some component of external funding) • Emergencies (SARS, Avian Influenza) • States can also directly obtain external funding for health but centre has to give clearance

8. Malaria Filariasis Kala azar Leprosy Tuberculosis Poliomyelitis HIV/AIDS Vaccine preventable diseases RCH Cancer control Blindness Mental Health Iodine deficiency Water supply Total Sanitation World Health Organization Country Office - India National Health ProgrammesSignificant surveillance componentDisease specific and vertical in approach

9. World Health Organization Country Office - India Statutory and administrative law issues • Statutory reform • Changes to existing legislations at national and state levels is an ongoing process • Disease surveillance is not a legal requirement at central level, but some states have it • Examples of existing legislations governing key IHR related issues • Public Health Act 1925 • Public Health emergencies Act being processed (Epidemic Diseases Act 1897 being repealed) • Prevention of extension of Infectious disease from one state to another (Concurrent list Entry 29) • Port quarantine (Union List entry 28, Constitution of India) • National Disaster Act 2005 • Right to Information Act 2005

10. World Health Organization Country Office - India Public Health Emergencies Act (under process) • To provide for the control and management of public health emergencies (including PHEIC) • Scope of the Act: • Dangerous epidemic disease (potential to spread rapidly) • Epidemic prone diseases (29 diseases + PHEIC when notified by WHO) • Bio-terrorism (34 agents + others) • Disasters (19 disasters + others) • Centre would have powers to direct states • Declare area of PHE for 3 months duration at a time • Need for a draft (model) PHE Act for countries to adapt

11. World Health Organization Country Office - India Vertical policy coordination and coherence • Current strategy • National Rural Health Mission, NHPs • All India Services – Bureaucrats (IAS, IPS), Central Government Health Scheme, etc • Regional Offices of Health & Family Welfare (cover all states/UTs) monitor implementation of central health schemes • Communications is entirely under Centre • Dispute resolution • Central Council for Health & Family Welfare

12. World Health Organization Country Office - India Fiscal and budgetary issues • Adequate resources to fulfill the basic obligations of IHR implementation • Funds would be required for capacity building at • Centre • State & districts • Public Health Laboratories • Border crossings • Port and airport health authorities • Hospitals for admitting large numbers of patients under isolation

13. World Health Organization Country Office - India IHR and non-governmental actors • Municipal Corporations especially large Metros • Defence • Airlines • Railways • Shipping • Travel & Tourism • Exporters • Hospitals • Media • NGOs

14. World Health Organization Country Office - India Media • Freedom of press a major factor in frequent reporting of outbreaks • Often report ‘mysterious illness/unknown disease’ which does alert international health networks. All disease outbreaks would fall in this category until lab confirmed. • 24 hr news channels (repeat the news, does create apprehension and also significant economic impact) • Health authorities use it to convey the status report • Play a positive role in IEC

15. World Health Organization Country Office - India Public health surveillance and response infrastructure • National Surveillance Programme for Communicable Diseases • Integrated Disease Surveillance Project (WB supported) for 5 years • Budgetary support planned under XI Five-year Plan • Laboratory strengthening under IDSP as well as additional funds for Pandemic Flu preparedness • Training of Health staff on-going

16. World Health Organization Country Office - India 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, lack of uniformity • Rapid Response Teams (RRTs) functioning but weak • Information was made available at National level only at monthly intervals

17. World Health Organization Country Office - India 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 all 35 states and UTs in the country. • In this programme the states were the implementing agencies and NICD Delhi was the Nodal agency for coordinating the activities. • This programme was 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.

18. World Health Organization Country Office - India Main components 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 had 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)

19. World Health Organization Country Office - India 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

20. World Health Organization Country Office - India Diseases/pathogens covered • Epidemic prone communicable diseases- acute diarrhoeal diseases including cholera, viral hepatitis, dengue, Japanese encephalitis, meningitis, measles, viral haemorrhagic fevers, leptospirosis, others • Pathogens with bioterrorism potential • Drug resistant pathogens

21. World Health Organization Country Office - India Expected outcome • Early detection of outbreaks • Early institution of containment measures • Reduction in morbidity & mortality • Minimize economic loss

22. World Health Organization Country Office - India Profile of outbreaks investigated by NSPCD districts

23. World Health Organization Country Office - India 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 600 districts in the country

24. World Health Organization Country Office - India Integrated Disease Surveillance Project (IDSP) • Integrated Disease Surveillance Project (IDSP) was conceptualized and the Govt of India approached the World Bank for the necessary funding (US $ 68 M over five yrs) • Objectives: • To establish a decentralized system of disease surveillance for timely and effective public health action • To improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies

25. Malaria ADD (Cholera) Typhoid Tuberculosis Measles Polio Plague Unusual Syndromes State Specific Diseases HIV, HBV, HCV Accidents Water Quality Outdoor Air Quality World Health Organization Country Office - India Target diseases in IDSP Sentinel Surveillance Regular Weekly Surveillance Community-based Surveys • NCD Risk factors

26. Phasing of Integrated Disease Surveillance Project World Health Organization Country Office - India Phase-I (04-05) Phase II (05-06) Phase III (06-07)

27. World Health Organization Country Office - India Organizational structure National Surveillance Committee Central Surveillance Unit State Surveillance Committee State Surveillance Unit District Surveillance Committee District Surveillance Unit

28. World Health Organization Country Office - India Information flow C.S.U. Weekly Surveillance System Sub-Centres Programme Officers S.S.U. P.H.C.s C.H.C.s D.S.U. Pvt. Practitioners Dist.Hosp. Nursing Homes Private Hospitals Med.Col. Private Labs. P.H.Lab. Other Hospitals: ESI, Municipal Rly., Army etc. Corporate Hospitals

29. World Health Organization Country Office - India Linkages at Central level Outbreak Investigation & Rapid Response W.H.O. E.M.R. NCD Surveillance MIS & Report RCH NACO NVBDCP RNTCP Programme Monitoring

30. Network of Reference Laboratories for Surveillance of in India World Health Organization Country Office - India Kasauli New Delhi Delhi Lucknow Dibrugarh Ahmedabad Kolkata Mumbai Proposed BSL-3 under ICMR Pune Bangalore Chennai L5 labs Pondicherry

31. World Health Organization Country Office - India Activities planned under National Rural Health Mission • Accredited Social Health Activist (ASHA) to be the community based informant for Disease Surveillance • Computerization up to PHC level, establishing connectivity with District Surveillance Unit • Setting up Distance Learning Communication Channel using EduSat • Strengthen Laboratory Services at PHC level

32. ROT TV/Monitor Teacher /Board Touch Screen DVD Player PC/ Web-Camera PTZ Camera SIT WLL World Health Organization Country Office - India Use of EDUSAT in Distance Learning & Communication for IDSP/NRHM EDUSAT REMOTE CLASSROOMS TEACHING END TEACHERS/STUDENTS RETURN LINK (Live Voice/ Voice Mail/Text Message)

33. World Health Organization Country Office - India Strengths of IDSP • Functional integration of surveillance components of vertical programmes • Reporting of suspect, probable and confirmed cases –syndromic reporting from periphery • Strong IT component for data analysis • Trigger levels for gradated response • Action component in the reporting formats • Streamlined flow of funds to the districts

34. WHO collaborative network Legend

35. World Health Organization Country Office - India Plan of Action

36. World Health Organization Country Office - India National Workshop of all Stakeholders for effective implementation of Revised IHR (2005), 20-21 April 2006 • To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities for surveillance and response (as per annex – 1A of IHR document) at National/State and District level • To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities (as per annex – 1B of IHR document) at Designated airports, Ports, and Ground crossings • To suggest a mechanism for: • Collaboration between different stakeholders at National / State/ District level and at designated Airports/ Ports/ Ground crossings • Addressing the administrative and legal issues related to implementation of IHR 2005

37. World Health Organization Country Office - India Planning forStrengthening of core capacities for surveillance and response

38. World Health Organization Country Office - India Planning forStrengthening of core capacities for surveillance and response (cont’d 2)

39. World Health Organization Country Office - India Planning forStrengthening of core capacities for surveillance and response (cont’d 3)

40. World Health Organization Country Office - India Planning forStrengthening of core capacities for surveillance and response (cont’d 4)

41. World Health Organization Country Office - India Planning forStrengthening of core capacities for surveillance and response (cont’d 5)

42. World Health Organization Country Office - India Planning forStrengthening of core capacities of ports and ground crossings

43. World Health Organization Country Office - India Planning forStrengthening of core capacities of ports and ground crossings (cont’d 2)

44. World Health Organization Country Office - India Planning forStrengthening of core capacities of ports and ground crossings (cont’d 3)

45. World Health Organization Country Office - India Planning forCollaborative, administrative and legal issues

46. World Health Organization Country Office - India Planning forCollaborative, administrative and legal issues (cont’d 2)

47. World Health Organization Country Office - India Obstacles to implementation • Inter-sectoral coordination (Av Flu) • Border crossings (large border and large number of migrants) • Frequent large outbreaks (daily 3-5 important outbreaks-presently Chikungunya, Japanese encephalitis, Leptospirosis)

48. Thank You