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

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

3. Disease surveillance Disease surveillance in India has always been practiced by the states (health being a state subject) 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 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 : - Rapid Response Teams (RRTs) (depending on the epidemic potential of these diseases) were called : - Malaria Response TeamsMalaria Response Teams Cholera Combat TeamsCholera Combat Teams Other disease specific Response TeamsOther disease specific Response Teams Little / no information was made available at National level Little / no information was made available at National level

4. National Health Programmes Significant surveillance component Disease specific Too vertical in approach Response at the district level is often delayed Malaria Malaria Filariasis Filariasis Kala azar Kala azar Leprosy Leprosy TB TB Polio Polio HIV/AIDS HIV/AIDS VPDs VPDs RCH RCH Cancer control Cancer control Blindness Blindness Mental Health Mental Health Iodine deficiency Iodine deficiency Water supply Water supply Total Sanitation Total Sanitation

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. 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. 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 Every state/UT and all the 101 districts has a trained multi-disciplinary Rapid Response Team Rapid communications (through e-mails & fax) Rapid communications (through e-mails & fax) Strengthening of state and district laboratories for rapid confirmation of diagnosis Strengthening of state and district laboratories for rapid confirmation of diagnosis Capacity development of health staff in the districts Capacity development of health staff in the districts IEC (information, education and communication) 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 Development of RRT guidelines, laboratory & computer manuals, and training materials Training of State Rapid Response Teams Training of State Rapid Response Teams Strengthening & networking of National and Regional laboratories Strengthening & networking of National and Regional laboratories Establishing rapid communication network Establishing rapid communication network Technical review, co-ordination, monitoring and evaluation 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 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 Modernization and computerization of state & district Epidemiology cell Strengthening of state / district laboratories Strengthening of state / district laboratories Improving sub-district mobility and communication Improving sub-district mobility and communication IEC 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: 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.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: Bacterial cultures & sensitivity testing: Stool C/S for enteric pathogens (Salmonella, Shigella, Vibrio cholerae); Blood C/SStool C/S for enteric pathogens (Salmonella, Shigella, Vibrio cholerae); Blood C/S Bacteriological water testing Bacteriological water testing Basic serology: Basic serology: Widal, HBV & HCV, VDRL, HIV, dengueWidal, HBV & HCV, VDRL, HIV, dengue Referral of specialized serology. 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 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 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 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 Review meetings- regional meetings half yearly in 2001, 2002, 2003 Field visits by experts throughout the year Field visits by experts throughout the year Independent Appraisals carried out in 2001 and December 2003 Independent Appraisals carried out in 2001 and December 2003

24. Achievements 1. Improved quality of detection, investigation and response to outbreaks 2. Rapid Response Teams with requisite knowledge and skills in place 3. Technical material on outbreaks investigation, manual on laboratory procedures and computer usage developed and made available in field

25. Achievements 4. Training in computer application for data processing and communication 5. Feedback mechanism in the form of “Outbreak News” & “CD Alert” and by frequent letters through e-mail/post 6. Improved capability of laboratories for etiological diagnosis 7. Rapid transmission of information 8. NICD Website www.nicd.org (includes NSPCD networking)

28. 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 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 GoI not convinced to expand this programme to all districts in the country

29. 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

30. Objectives of IDSP Establish a decentralized system of disease surveillance for timely and effective public health action 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 Improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies

31. IDSP Based on case based reporting Syndromic surveillance (suspect case reporting at PHC and below) Syndromic surveillance (suspect case reporting at PHC and below) Confirmed case reporting of selected priority diseases (at district level) Confirmed case reporting of selected priority diseases (at district level) Passive reporting of Road Traffic Accidents and Air Pollution. Passive reporting of Road Traffic Accidents and Air Pollution.

32. Syndromic surveillance Fever<7 days (alone, with rash, with altered sensorium/convulsions, bleeding skin/gums Fever<7 days (alone, with rash, with altered sensorium/convulsions, bleeding skin/gums Fever>7 days Fever>7 days Cough>3 weeks Cough>3 weeks AFP AFP Diarrhea Diarrhea Jaundice Jaundice Unusual events causing death/hospitalization Unusual events causing death/hospitalization

33. Target diseases Malaria Malaria ADD(Cholera) ADD(Cholera) Typhoid Typhoid Tuberculosis Tuberculosis Measles Measles Polio Polio Plague Plague HIV, HBV, HCV HIV, HBV, HCV Unusual Syndromes Unusual Syndromes Accidents Accidents Water Quality Water Quality Outdoor Air Quality Outdoor Air Quality NCD Risk factors NCD Risk factors State Specific Diseases State Specific Diseases

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

35. Level of responses Trigger-1 : Response Health Workers Trigger-1 : Response Health Workers Trigger-2 : Outbreak Inv. & Response (PHCs/ CHCs) Trigger-2 : Outbreak Inv. & Response (PHCs/ CHCs) Trigger-3 : Outbreak Inv. & Resp. (DSU) Trigger-3 : Outbreak Inv. & Resp. (DSU) Trigger-4 : Epidemic Response (SSU) Trigger-4 : Epidemic Response (SSU) Trigger-5 : Disaster Response (CSU) Trigger-5 : Disaster Response (CSU)

36. 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.

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

38. District Surveillance Committee Chairperson* District Surveillance Committee District Surveillance Officer (Member Secretary) CMO (Co. Chair) Representative Water Board Superintendent Of Police IMA Representative NGO Representative District Panchayat Chairperson Chief District PH Laboratory Medical College Representative if any Representative Pollution Board District Training Officer (IDSP) District Data Manager (IDSP) District Program Manager Polio, Malaria, TB, HIV - AIDS * District Collector or District Magistrate

39. STRUCTURAL FRAMEWORK C.S.U.S.S.UD.S.U.P.S.U MED COL. DIST HOS. PVT. HOS. OTHER HOS. LABS SUB CENTRES PHCs/CHCs RURAL PPs

40. Formats & manuals Standard Case Definitions Standard Case Definitions Standard Formats for reporting Standard Formats for reporting Operations manual for Health Workers, Medical Officers, Laboratory Technicians and District/State Surveillance Teams Operations manual for Health Workers, Medical Officers, Laboratory Technicians and District/State Surveillance Teams Standard user friendly training manuals Standard user friendly training manuals

41. NCD risk factor surveillance Monitor trends of important risk factors of NCD in the community over a period of time 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 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 Strengthen NCD surveillance at District level Integrate NCD risk factor surveillance with IDSP Integrate NCD risk factor surveillance with IDSP

42. Strengths of IDSP Functional integration of surveillance components of vertical programmes Functional integration of surveillance components of vertical programmes Reporting of suspect, probable and confirmed cases Reporting of suspect, probable and confirmed cases Strong IT component for data analysis Strong IT component for data analysis Trigger levels for gradated response Trigger levels for gradated response Action component in the reporting formats Action component in the reporting formats Streamlined flow of funds to the districts Streamlined flow of funds to the districts

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

44. Integration ?! What exactly do we expect in integration What exactly do we expect in integration Functional integration to what degree Functional integration to what degree Vertical programmes will continue Vertical programmes will continue NCD component invariably stand alone NCD component invariably stand alone IEC, Training, Formats- consultation with these programmes IEC, Training, Formats- consultation with these programmes Fund sharing a daunting task Fund sharing a daunting task

45. Disease Surveillance Lessons learnt / Issues

46. Lessons learnt NSPCD No budget for NSPCD nodal cell No budget for NSPCD nodal cell No integration No integration No budget for retraining No budget for retraining Feedback inadequate Feedback inadequate Weak IT component Weak IT component Weak state ownership (selected districts) Weak state ownership (selected districts) Slow financial flow Slow financial flow Weak M & E, supervision Weak M & E, supervision Weak Advocacy Weak AdvocacyIDSP IDSP cell in Ministry with budget IDSP cell in Ministry with budget Integration Integration Budget for retraining Budget for retraining Adequate feedback planned Adequate feedback planned Strong IT component Strong IT component Strong state ownership (all districts) Strong state ownership (all districts) Fast financial flow Fast financial flow Strong M & E, supervision Strong M & E, supervision Advocacy at all levels Advocacy at all levels

47. National Issues Political considerations based on Centre-state relations Political considerations based on Centre-state relations Central assistance proportionate to political affiliations Central assistance proportionate to political affiliations Media attention an important consideration for response Media attention an important consideration for response Time constraints-inadequate time given for outbreak investigation Time constraints-inadequate time given for outbreak investigation Hesitancy for international assistance either in Outbreak Investigation or Lab support Hesitancy for international assistance either in Outbreak Investigation or Lab support

48. National Issues cont’d Reduced attendance in public health system and increased in private sector almost 40:60 or more 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) 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 ‘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 Lack of ownership by states of central vertical programmes

49. State issues State RRT not utilized to full potential State RRT not utilized to full potential Regional labs strengthened but lab diagnosis not enhanced & increasing dependence on Centre Regional labs strengthened but lab diagnosis not enhanced & increasing dependence on Centre Insufficient epidemiological analysis Insufficient epidemiological analysis No clear IEC strategy No clear IEC strategy Frequent transfer/retirements of trained staff so programme invariably suffers Frequent transfer/retirements of trained staff so programme invariably suffers Shortage of staff so multi-tasking for state and district level functionaries. Shortage of staff so multi-tasking for state and district level functionaries. Fund issues and Utilization certificates Fund issues and Utilization certificates

50. 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. 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 Clear demarcation between the Directorate of Health Services and Directorate of Medical Education so difficulties in integrating Medical colleges

51. District issues Programme is focused on district epidemic preparedness and response but some districts yet to get their act together 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 Reporting from periphery needs improvement. If media first reporting then SURVEILLANCE FAILURE Weekly reports incomplete and irregular (and under reporting) Weekly reports incomplete and irregular (and under reporting) Monthly reports also irregular (CBHI has to increase its role & responsibility) Monthly reports also irregular (CBHI has to increase its role & responsibility) Communication ‘failure’ Communication ‘failure’ CMO-CMS-DSO lack of co-ordination CMO-CMS-DSO lack of co-ordination

52. District issues cont’d Overworked peripheral staff to whom all programmes are dependent on Overworked peripheral staff to whom all programmes are dependent on Multiple formats for different programmes 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 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 Concept of Nil reporting/routine reporting difficult for the peripheral staff to understand, compounded by lack of feedback from the higher levels

53. District lab issues District labs few established and functioning satisfactorily District labs few established and functioning satisfactorily Many labs in a district: Many labs in a district: Public health lab-testing water samplesPublic health lab-testing water samples Hospital lab-testing for NCDs and clinical requirementsHospital lab-testing for NCDs and clinical requirements Medical College lab-testing for majority of the diseasesMedical College lab-testing for majority of the diseases Surveillance lab-testing for few diseasesSurveillance lab-testing for few diseases District blood bank –with ELISA readerDistrict blood bank –with ELISA reader Peripheral labs-Microscopy onlyPeripheral labs-Microscopy only Co-ordination between these labs so that overall district lab capacity enhanced

54. Thank You