Disease Surveillance in India

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Disease Surveillance in India

• Dr Sampath K Krishnan
• National Professional Officer (Communicable
  Diseases Surveillance)

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Presentation

• Disease surveillance
• NSPCD
• IDSP
• Lessons Learnt/Issues

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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

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

• Malaria
• Filariasis
• Kala azar
• Leprosy
• TB
• Polio
• HIV/AIDS
• VPDs

• RCH
• Cancer control
• Blindness
• Mental Health
• Iodine deficiency
• Water supply
• Total Sanitation

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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.

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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.

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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.

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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)

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Districts covered under NSPCD
1997-98 (25 districts)
1998-99 (20 districts)
2000-01(35 districts)
2001- 02 (201 districts)
The district of Shimla taken as a special case
during 2002-03
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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

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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

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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

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Expected outcome

• Early detection of outbreaks
• Early institution of containment measures
• Reduction in morbidity mortality
• Minimize economic loss

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Weekly reports received from NSPCD districts
during 2001, 2002 2003 Jan - June
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Weekly reports received from NSPCD districts
during 2001,2002 2003 July-Dec
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Monthly reports received during 2001, 2002
2003 from NSPCD districts
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Month-wise outbreaks 2001, 2002 2003
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Profile of outbreaks investigated by NSPCD
districts
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Laboratory strengthening District
laboratories
WATER STOOL C/S
WATER ONLY
NO WATER NO STOOL C/S
NO INFORMATION
NON NSPCD DISTRICTS
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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.

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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

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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

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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

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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

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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)

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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

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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

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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

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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.

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Syndromic surveillance

• Feverlt7 days (alone, with rash, with altered
  sensorium/convulsions, bleeding skin/gums
• Fevergt7 days
• Coughgt3 weeks
• AFP
• Diarrhea
• Jaundice
• Unusual events causing death/hospitalization

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Target diseases

• Unusual Syndromes
• Accidents
• Water Quality
• Outdoor Air Quality
• NCD Risk factors
• State Specific Diseases

• Malaria
• ADD(Cholera)
• Typhoid
• Tuberculosis
• Measles
• Polio
• Plague
• HIV, HBV, HCV

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Project components

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

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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)

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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.

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Organizational Structure

• Disease Surveillance Committee
• Executive Committee
• Disease Surveillance Unit

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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
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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
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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

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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

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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

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Integration

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

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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

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Disease Surveillance Lessons learnt / Issues
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Lessons learnt

• 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

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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

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National Issues contd

• Reduced attendance in public health system and
  increased in private sector almost 4060 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

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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

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State issues contd

• 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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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

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District issues contd

• 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

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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

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Thank You