1. Integrated Disease Surveillance Programme
Presenter : Dr. Aakash Jivane
Moderator: Dr. P. R. Deshmukh

2. FRAME WORK:
1. Introduction
2. Integrated Disease Surveillance Project (IDSP)
3.Types of Surveillance in IDSP
4. Reporting Units participating in regular passive surveillance under IDSP
5. Outbreak Response
6. Analysis of Data
7. Surveillance Action
8. Feedback
9. References

3. Introduction
IDSP is a decentralized, state based surveillance programme in the country.
Launched in 2004 by Ministry of Health and Family Welfare with World Bank assistance.
Intended to detect early warning signals of impending outbreaks.
Helps to initiate an effective response in a timely manner.
Total budget from 2004 to 2009 was cores.
Also expected to provide essential data to monitor progress of on-going disease control programmes
All the outbreaks cannot be predicted or prevented . But precautionary measures can be taken within the existing health infrastructure and service to reduce the outbreaks

4. Course of epidemic depends on how early the outbreaks is identified and how effectively specific control measure are applied.
When the outbreaks occur or when the risk of such outbreaks his high, the co-operation of other government department, non-government agencies and community often becomes necessary.
Frequency of the occurrence of epidemics indicates inadequacy of the surveillance system and preparedness to identify and control outbreaks in a timely manner.

5. Public Health Surveillance
Ongoing systematic collection, analysis and interpretation of health data essential to planning, implementation and evaluation of public health practice closely integrated with timely dissemination of these data to those who need to know.
Surveillance is the backbone of public health programme .
Provides information so that the effective action can be taken to control and prevent disease of public health importance.

6. Key Elements of Surveillance System
Six key elements
Detection and notification of health event.
Investigation and confirmation (epidemiological, clinical, laboratory)
Collection of data
Analysis and interpretation of data
Feed back and dissemination of result
Response

7. Levels where surveillance activites performed

8. Uses of surveillance
Recognize cases or cluster of cases to trigger interventions to prevent transmission or reduce morbidity and mortality
Assess the public health impact of health events and determine their trends
Demonstrate the need for public health intervention programs and resources and allocate resources during public health planning
Monitor effectiveness of prevention and control measures. Identify high-risk groups or geographical areas to target interventions and guide analytic studies
Develop hypothesis that lead to analytic studies about risk factors for disease causation, propagation or progression.

9. In the integrated disease surveillance system
The district level is the focus for integrating surveillance functions.
All surveillance activities are coordinated and streamlined. Rather than using scarce resources to maintain vertical activities, resources are combined to collect information from a single focal point at each level.
Several activities are combined into one integral activity to take advantage of similar surveillance functions, skills, resources and target populations.
The IDSP integrates both public and private sector by involving the private practitioners, private hospitals, private labs, NGOs, etc and also emphasis on community participation.
The IDSP integrates communicable and non-communicable diseases. Common to both of them are their purpose in describing the health problem, monitoring trends, estimating the health burden and evaluating programmes for prevention and control.
Integration of both rural and urban health systems as rapid urbanization has resulted in the health services not keeping pace with the growing needs of the urban populace. The gaps in receiving health information from the urban areas needs to be bridged urgently.
Integration with the medical colleges (both private and public) would also qualitatively improve the disease surveillance especially through better coverage.

10. Main Objective of IDSP
To establish a decentralized district-based system of surveillance for communicable and non-communicable diseases so that timely and effective public health actions can be initiated in response to health challenges in the urban and rural areas
To integrate existing surveillance activities (to the extent possible without having a negative impact on their activities) so as to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders, so that valid data are available for decision making at district, state and national levels.

11. Specific objectives
To integrate coordinate and decentralize surveillance activities.
To survey a limited number of health conditions and risk factor.
Establish system for quality data collection, reporting, analysis and feedback using information technology
Improve laboratory support for disease surveillance.
Develop human resources for disease surveillance.
Involve all stakeholder including private sector and communities in surveillance.

12. Diseases and core condition under IDSP
Regular Surveillance∗:
Vector Borne Disease : 1. Malaria
Water Borne Disease : 2. Acute Diarrhoeal Disease (Cholera)
: 3. Typhoid
: 4. Jaundice
Respiratory Diseases : 5. Tuberculosis
: 6. Acute Respiratory Infection
Vaccine Preventable Diseases : 7. Measles
Diseases under eradication : 8. Polio
Other Conditions : 9. Road Traffic Accidents
(Linkup with police computers)
Other International commitments : 10. Plague, Yellow fever
Unusual clinical syndromes : 11. Menigoencephalitis/ Respiratory
(Causing death/hospitalization) Distress, Haemorrhagic fevers, other undiagnosed conditions

13. Sentinel Surveillance:
Sexually transmitted diseases/Blood borne : 12. HIV, HBV, HCV
Other Conditions : 13. Water Quality
: 14. Outdoor Air Quality
(Large Urban centres)
Regular periodic surveys:
NCD Risk Factors : 15. Anthropometry, Physical Activity,
Blood Pressure, Tobacco, Nutrition
State specific diseases : e.g. Dengue, Japanese Encephalitis, Leptospirosis

14. To plan any disease control programme and to identify and control outbreaks, it is important to know the following:
Who get the diseases?
How many get them?
Where do they get them?
When do they get them?
Why do they get them?

15. 5 steps in surveillance procedure (carried out at each level)
Collection of data
Compilation of data
Analysis and interpretation
Follow up action
Feedback

16. Pre-requisites for effective surveillance
Use of standard case definitions
Ensure regularity of the reports
Action on the reports

17. For effective development of disease surveillance system DHO/ MO PHC must clear about
What information to gather?
How often to compile and analyse the data?
How often and to whom to report?
What proforma or formats to use?
What action to take?

18. Types of Surveillance in IDSP
1. Syndromic – Diagnosis made on the basis of symptoms/clinical pattern by paramedical personnel and members of the community.
2. Presumptive (Clinical) – Diagnosis made on typical history and clinical examination by Medical Officers.
3. Confirmed(Laboratory) – Clinical diagnosis confirmed by an appropriate laboratory test.

19. Syndromic Surveillance
Carried out by paramedical staff
Clinical syndromes under surveillance
Fever
Cough with or without fever
Acute Flaccid Paralysis
Diarrhoea
Jaundice
Unusual events causing death or hospitalization

20. Methods for data collection
Sentinel surveillance
Active surveillance (active search for cases)
Vector surveillance
Laboratory surveillance
Sample surveys
Outbreak investigations
Special studies

21. Phasing of IDSP covering states of India
Phase 1: (financial year )
A.P, Himachal Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Uttaranchal, Tamil Nadu, Mizoram and Kerala.
Phase 2: (financial year )
Chhattisgarh, Goa, Gujarat, Rajasthan, West Bengal Manipur, Meghalaya, Orissa, Tripura, Chandigarh, Pondicherry, Delhi.
Phase 3: Financial year )
U.P, Bihar, J.K, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland, Sikkim, Andaman& Nicobar, Diu & daman, Lakshadweep.

22. Project Activity Decentralizing and Integrating Surveillance
Up gradation of Laboratories.
Use of Information and Technology
Human Resources and Development
Operational Activities and Responses
Monitoring and Evaluation

24. Administrative Structure

26. Function of National Surveillance Unit
Execution of Approved annual plan of action for IDSP.
Monitor progress of implementation of the project.
Seek reimbursement from the World Bank through controller of Account.
Report to National disease surveillance committee regularly.
Production and dissemination of prototype, guidelines, manuals and modules.
Implement central level activities.
Coordinate with ICMR, NICD and other

27. Analysis of data from states and provide feedback on trends observed.
Organize surveys on noncommunicable disease and risk factor.
Conduct periodic review meeting state surveillance officer.
Organize independent evaluation of various activities.

28. At State level Chairperson- State Secretory Health

29. Function of State surveillance unit
Collation and analysis of data received from district and transmitting to CSU.
Coordinating activities of rapid response team and deputing them to the field.
Monitoring and reviewing the activities of the district surveillance units including checks on validity of data, responsiveness and functioning of the laboratories.
Coordinating the activities of the state public health laboratories.

30. Sending regular feedback to the district unit on the trend analysis of data.
Coordinating all training activities under the project.
Organization of meetings of the state surveillance committee.

31. At District level Chairperson- District Collector or District Magistrate

32. Functions of DSU
Collation and analysis of data received from all reporting units and transmission to SSU.
Constituting rapid response teams and deputing them to the field whenever needed.
Implementation and monitoring of all project activities.
Coordinating activities of the public health laboratories, medical college, NGOs, and Private sector

33. Sending regular feedback to the reporting units on analysis of data.
Organizing training and IEC activities within the district.
Organizing meeting of the district surveillance committee.

34. Reporting Units for disease Surveillance
Rural Area
Urban area
Public health sector
PHCs/CHCs, Sub District and District Hospitals
Urban hospitals, ESI, Railway, CGHS hospitals and dispensaries, Medical college, Municipal Corp. hospitals and dispensaries
Private Health sector
Sentinel private practioners and Sentinel
Hospitals
Sentinel private nursing home , Sentinel Hospitals, Medical colleges, NGOs and private laboratories.

35. Involvement of Private Sector
Strategic alliance through professional association. (IMA, IAP)
Selection by volume of target diseases, geographical coverage, credibility and willingness to participate.
Providing linkages through web or transmission by , fax/telephone/ courier.
Recognition and partnership.

36. Involvement of Medical College
Each Medical College will be integrated into this surveillance system
Their role in providing following services are acknowledge:
Reference Laboratories
Quality assurance
Training
Epidemic investigation
Non Communicable disease surveillance.

38. Data Management
Under IDSP data is collected on a weekly basis(Monday- Sunday).
Data collected on three specified reporting formats, namely S, P, L forms filled by Health worker, clinician, clinical laboratory staff.
The Weekly data gives the time trends.
Whenever rising trend of illness in any area is noticed, it is investigated by the Medical Officer/ Rapid Response Team to diagnose and control of outbreaks.
Data analysis is carried out by their respected units.

44. Outbreak Response
Def- Occurrence of two or more epidemiologically linked cases of a disease of outbreak potential.(measles, cholera ,dengue, JE,AFP or plague OR
Occurrence of cases of an illness in a community clearly in excess of expected number
Outbreak is usually limited to a small focal area whereas epidemic covers large geographic area and has more than one focal point.

45. Active Case Based Surveillance
Initiated by the MO I/C of the CHC and PHC in response to a suspected epidemic in following situation:
A community member reports unexptected occurrence of cases
The MPW detects unexpected occurence of cases during his/her routine home visit
The Mobile team identifies cases during village visits
The media reports clustering of cases in a community or area e.g. outbreak of severe illness suggesting Malaria in a village and epidemic investigation is initiated

46. Detecting an Outbreak There are various ways of detecting outbreaks
Rumor Register
Media
Review of routine data
Warning signs of an impending outbreaks

47. Rumor Register Maintained in each public health facility.
Source of information is verified to identify outbreaks.
Key informants in community is motived to become eyes and ear of health services of community.
I/C MO should investigate all rumors of epidemic prone disease recorded in rumor register.
This data send weekly to DSO with weekly report.

48. Media
Effective source of information on any unusual health event in the community.
This important source should not be neglected by the health authorities.
The weekly report on rumor should be action based indicating response to rumor.

49. Review of routine data
It is one of the common way early detection of outbreak.
Check whether it crosses the threshold levels.
If the cases are approaching the threshold level or has crossed it then outbreak should be suspected.

50. Warning signs of an impending outbreak
Even a single case of measles, AFP, Cholera, Plague, dengue or JE
Acute febrile illness of unknown aetiology
Occurrence of two or more epidemiologically linked cases of meningitis
Shifting in age distribution of cases
Sudden increase / high vector density
Lab related warning signals

51. Reporting an Outbreak
At the PHC, CHC MO I/C is the nodal officer responsible to respond to an outbreak.
At district, District Epidemic Investigation
Team/Rapid Response Team will have the primary responsibility to investigate outbreaks.
If an outbreak is suspected, the local health team should verify the same.
A First Information Report will be submitted to the District Surveillance Officer by the fastest route to facilitate action.

52. Analysis of Data
Analyse and interpret the data received within 24 hours
Compare analysis results with thresholds to identify outbreaks.
While collection of good quality data is important for a surveillance programme, analysis and interpretation of this data is of equal significance. Without this, all the hard work put in by the workers becomes meaningless.

53. Data Analysis provides three important outcomes: • Frequency count by reporting unit helps in identifying outbreaks or potential outbreaks. • During an outbreak, analysis of the data identifies the most appropriate and timely control measures. Analysis in terms of person, time and place will be able to focus the intervention; e.g. analysis of a suspected and confirmed cases of Malaria will be able to identify the affected families and the cause of the outbreak so that corrective action can be targeted at this cause. • Analysis of routine data provides information for predicting changes of disease rates over time and enables appropriate action

54. Level of Response
1. Trigger Level-1 Suspected /limited outbreak – Local response by MO. 2. Trigger Level-2 Epidemic – Local & Regional Response by DSO and RRT. 3. Trigger Level -3 Wide spread Epidemic (established outbreak) – Local, Regional and state level response. 4. Trigger Level 4 – National level response. 5. Trigger Level 5 – International level response.

55. In the event of an outbreak
a). In a non endemic area even 1 case of suspected epidemic prone disease should initiate a trigger response at various levels
b) . In an endemic region change in pattern of disease or evidence of clustering of disease should be considered a trigger event.
In an established outbreak, the response includes the following simultaneous actions:
1. Emergency Case Management
2. Referral to an appropriate level of care
3. Epidemiological Investigations
4. Laboratory Investigations to identify the aetiology
5. Presumptive & definitive control measures
6. Upgrading response to a higher level by informing the DSO if outbreak is confirmed.

56. Feedback
Feed back is essential to maintain and support the peripheral staff.
Feed back report should be sent regularly once a month even when there are no epidemics in the area.
The data should represent trends over time in the district.
Feed back report should also be provided on the quality of data submitted to the district surveillance officer .

57. Interpretation of Reports

60. Training Manual for Paramedical Staff For Hospital Based Disease Surveillance