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Framework for implementation of revised IHR 2005 in India


Title: Disease Surveillance in India Author: krishnans Last modified by: C WM Created Date: 2/22/2004 11:19:42 AM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Framework for implementation of revised IHR 2005 in India

Framework for implementation of revised IHR 2005
in India
  • Dr Sampath K Krishnan
  • Coordinator CDS IHR Contact Point

  • Health Legislation Governance
  • Disease surveillance
  • IDSP
  • Plan of action for implementation of IHR in India

Constitutional allocation of Government powers
  • Federal structure - Health is a state subject in
    the main
  • Central (Union) list, State list Concurrent
  • 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

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
  • Poultry farmers supported culling operations.
  • Protests could occur even if legislations are in

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
  • 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)

Federal system
  • Health is a state subject in the main hence
    states usually enact their own health
  • 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
  • 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)

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

National Health ProgrammesSignificant
surveillance componentDisease specific and
vertical in approach
  • Malaria
  • Filariasis
  • Kala azar
  • Leprosy
  • Tuberculosis
  • Poliomyelitis
  • Vaccine preventable diseases
  • RCH
  • Cancer control
  • Blindness
  • Mental Health
  • Iodine deficiency
  • Water supply
  • Total Sanitation

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
  • Port quarantine (Union List entry 28,
    Constitution of India)
  • National Disaster Act 2005
  • Right to Information Act 2005

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
  • 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
  • Need for a draft (model) PHE Act for countries to

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

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

IHR and non-governmental actors
  • Municipal Corporations especially large Metros
  • Defence
  • Airlines
  • Railways
  • Shipping
  • Travel Tourism
  • Exporters
  • Hospitals
  • Media
  • NGOs

  • 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
  • Health authorities use it to convey the status
  • Play a positive role in IEC

Public health surveillance and response
  • National Surveillance Programme for Communicable
  • 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

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

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

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
  • IEC (information, education and communication)

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
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

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

Profile of outbreaks investigated by 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
  • GoI not convinced to expand this programme to all
    600 districts in the country

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

Target diseases in IDSP
Sentinel Surveillance
Regular Weekly Surveillance
  • Malaria
  • ADD (Cholera)
  • Typhoid
  • Tuberculosis
  • Measles
  • Polio
  • Plague
  • Unusual Syndromes
  • State Specific Diseases
  • Accidents
  • Water Quality
  • Outdoor Air Quality

Community-based Surveys
  • NCD Risk factors

Phasing of Integrated Disease Surveillance Project
Phase-I (04-05)
Phase II (05-06)
Phase III (06-07)
Organizational structure
  • National Surveillance Committee
  • Central Surveillance Unit
  • State Surveillance Committee
  • State Surveillance Unit
  • District Surveillance Committee
  • District Surveillance Unit

Information flow
Weekly Surveillance System
Programme Officers
Pvt. Practitioners
Nursing Homes
Private Hospitals
Private Labs.
Other Hospitals ESI, Municipal Rly., Army etc.
Corporate Hospitals
Linkages at Central level
Outbreak Investigation Rapid Response
NCD Surveillance
MIS Report
Programme Monitoring
Network of Reference Laboratories for
Surveillance of in India
New Delhi
Proposed BSL-3 under ICMR
L5 labs
Activities planned under National Rural Health
  • Accredited Social Health Activist (ASHA) to be
    the community based informant for Disease
  • 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

Use of EDUSAT in Distance Learning
Communication for IDSP/NRHM
RETURN LINK (Live Voice/ Voice Mail/Text Message)
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

WHO collaborative network
  • Plan of Action

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

Planning forStrengthening of core capacities for
surveillance and response
1 Strong linkages between IHR IDSP June 2006 IDSP, NFP
2 Strong component of IHR in all IDSP trg December 2006 IDSP, NFP
3 All RRTs should be aware of the information needed to be reported December 2006 IDSP, NFP
4 Increase awareness about IHR among administrators and politicians at national / state/ district levels December 2006 IDSP, NRHM, IH
5 Electronic transmission of data including GIS from phase I districts December 2006 IDSP
6 Electronic transmission of data from districts under phase II of IDSP June 2007 IDSP
7 Electronic transmission of data from districts under phase III of IDSP December 2007 IDSP
8 Designation of surveillance officers of state district surveillance units as state/ district IHR focal points December 2006 IDSP
9 Mechanism for rumor verification to be strengthened at district/ state/ national level June 2007 IDSP
Planning forStrengthening of core capacities for
surveillance and response (contd 2)
10 Evaluation of laboratory capacities at state and district levels and their strengthening December 2006 IDSP State Governments
11 At least one laboratory (L4 level of IDSP) in each state (more in bigger states) to be identified / strengthened December 2007 State Governments IDSP
12 At least one BSL4 laboratory under the Ministry of Health, GOI which should be linked to IDSP and NFP December 2008 MOHFW
13 Preparation for state / district health contingency plans and their periodical updating December 2007 State Governments
14 Evaluation of isolation facilities and hospital infection practices in all districts/ states December 2007 State Governments
15 Involvement of private sectors for disease surveillance by sensitization, persuasion, training, legislation and also through professional organizations like IMA December 2007 State Governments IDSP
16 GOI may expedite approval of Public Health Emergency Act 2005 December 2006 MOHFW
17 All surveillance officers to have the list of big and small international airports, ports and ground crossings and invite them in surveillance meetings December 2006 IDSP State Governments
Planning forStrengthening of core capacities for
surveillance and response (contd 3)
18 APHOs/ PHOs to be included in the state surveillance committees December 2006 IDSP, Min of Shipping, Civil Aviation, DGHS
19 Assessment of disease surveillance and response capacity as mentioned under the IHR-identification of responsible agency, preparation of assessment instrument methodology and provision of resources June 2007 IDSP, MOHFW
20 Establishment of a mechanism for periodic independent evaluation of IDSP June 2007 IDSP
21 National RRT must be involved for investigation of events if more than one state is involved December 2006 IDSP State Governments
22 State RRT must be involved for investigation of events if more than one district is involved December 2006 IDSP, MOHFW
23 A copy of the investigation report should be given to the district collector or Municipal commissioner December 2006 IDSP, MOHFW, State govts MHA
24 Findings of investigations of central RRT should be urgently conveyed to states and the findings of state RRT should be urgently conveyed to district December 2006 MOHFW, State Governments
25 All major laboratories in the country testing clinical samples should start reporting to IDSP December 2006 IDSP
Planning forStrengthening of core capacities for
surveillance and response (contd 4)
26 Identification of high-risk areas near the international borders and establish/activate the programme for cross border control of diseases June 2007 IDSP, State Govts., MOHFW, MEA
27 Strengthening of capacity including trained manpower for disease surveillance and response at central level (e.g., NICD, Emergency Medical Response division of Dte. GHS), to provide support to the states during PHEIC December 2007 MOHFW
28 The proposal for conversion of NICD to National Centres for Disease Control (NCDC) may be put on fast track December 2007 NICD, MOHFW
29 Strengthening of capacity for disease surveillance and response at state and district level December 2007 State Govts
30 Involvement of major institutions and National Health Programmes like ICMR, NVBDCP in assessment and investigation of public health events December 2006 MOHFW
Planning forStrengthening of core capacities for
surveillance and response (contd 5)
31 Existing disease control guidelines to be updated and widely circulated, issue new guidelines for emerging diseases, and their periodic updating June 2007 NICD IDSP
32 National IHR focal point (NICD) should have the linkages with international reference labs and should have the authority to directly send the biological material to them December 2006 NICD, MOHFW
33 Satellite linkages of IDSP and national IHR focal point with all state and district HQs June 2007 IDSP
34 Establishment of mechanism for collaboration and coordination between different Ministries/ Departments June 2007 MOHFW
35 Preparation of a National Public Health Emergency Response Plan December 2007 IHR focal point, MOHFW, MHA
Planning forStrengthening of core capacities of
ports and ground crossings
1 Identification of airports, ports and ground crossings for implementation of IHR June 2006 MOHFW (ADG,IH) M/O Civil Aviation M/O Shipping MHA
2 Assessment of present capacities at the designated airports, ports and ground crossings June 2007 M/O Civil Aviation M/O Shipping MHA MOHFW (ADG,IH)
3 Taking a policy decision about who will provide the health services at the designated airports, ports and ground crossings (in context of privatization) December 2006 M/O Civil Aviation M/O Shipping MHA
4 Filling up of vacant posts for strengthening of medical services at the designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW
5 Establishing a referral system for medical services at the designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW
Planning forStrengthening of core capacities of
ports and ground crossings (contd 2)
6 Creation of new public health units at designated ports, airports and ground crossings (at present there are 6 APHOs, 8 PHOs and one ground level Health organization) December 2007 MOHFW
7 Improvement of physical infrastructure of quarantine centers at designated airports, ports and ground crossings December 2007 MOHFW
8 Training of technical staff of designated airports, ports and ground crossings on IHR (2005) December 2007 MOHFW NFP IDSP
9 Provision of ambulance at all designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW
10 District IDSP laboratories be designated for each airport/ port/ ground crossing health organizations June 2007 MOHFW, IDSP State Govts. M/O Civil Aviation M/O Shipping MHA
Planning forStrengthening of core capacities of
ports and ground crossings (contd 3)
11. Provision of entomologist at all the health units for vector surveillance and control activities December 2007 MOHFW
12. Linkages with IDSP Link with website Networking with IDSP laboratories June 2007 MOHFW, IDSP State Govts.
13. Preparation of Public Health Emergency Contingency plan including Preparation of panel of doctors/ paramedical staff for deputation during Public Health Emergency Identifying referral laboratories and medical facilities Coordination amongst Designated hospitals, Department of Animal Husbandry, Designated laboratories, Immigration contact point, Airport/ ship management agencies, Customs contact point December 2007 MOHFW (ADG,IH)
Planning forCollaborative, administrative and
legal issues
1 Examination of IHR (2005) document for administrative and legal issues July 2006 MOHFW
2 Examination of health certificates/ documents and charges mentioned in IHR (2005) and to revise national certificates/ documents and charges, if necessary, and communicate to the WHO June 2007 MOHFW
3 Examination of National Aircraft/Port Health Act and Rules and to revise/amend them, if necessary, for effective implementation of IHR (2005) June 2007 MOHFW
4 Prepare/Update Health rules for designated Ground Crossings June 2007 MOHFW MHA
Planning forCollaborative, administrative and
legal issues (contd 2)
5 Presently MHA provides emergency support services and coordination between different sectors during emergencies. The same mechanism should be used for the purpose of Public Health Emergencies of International Concern under the IHR. December 2006 MOHFW, MHA
6 Coordination committees Mechanism for coordination and collaboration between different sectors at various levels (National, State and District) already exists under IDSP. These committees should be suitably expanded for the purpose of IHR. Nodal members to be identified from the following ministries/ organizations MOHFW Designated hospitals, laboratories and various pest/ vector control agencies State Health Directorates, District Health Authorities Local municipality, cantonment board, any other relevant agency Ministries of Civil Aviation, Shipping, Surface transport, Agriculture (veterinary dept.), Home Affairs, Tourism, Railways Customs, Immigration, AAI Association of shipping agents CISF December 2007 MOHFW, MHA
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)

  • Thank You