1. Setting up the Integrated Disease Surveillance Programme (IDSP) at district level Integrated Disease Surveillance Programme (IDSP) district surveillance officers (DSO) course

2. 2 Preliminary questions to the group Were you involved in setting up surveillance your district? If yes, what difficulties did you face? What would you like to learn about setting up surveillance?

3. 3 Outline of the session 1.Warm up session 2.Initiating surveillance 3.The district surveillance unit 4.Initiating passive surveillance

4. 4 Warm up session: A Bhutanese village close to the state of West Bengal, India Number of blood slides collected for malaria monitored over time Data analyzed for 2001-4 Warm up

5. 5 Number of blood slides tested for malaria in Phuentsholing, Bhutan, 2001-2004 0 100 200 300 400 500 600 13579 111315171921232527293133353739414345474951 Weeks Number of slides tested for malaria 2004 2003 2002 2001 Warm up

6. 6 What happened in 2004? Observe the data  What do you see? Interpret the information  What action will you take? Warm up

7. 7 Fever cases in Phuentsholing, 2004 What is to be seen?  Peak in the number of blood smears requests in 2004  Peak is in excess to what was usually seen in this season What to do?  The increase in the number of fever cases suggests an outbreak that needs to be investigated  Although not designed for this, this imperfect surveillance system captured an outbreak of Dengue Warm up

8. 8 What happened in 2003? Observe the data  What do you see? Interpret the information  What action will you take? Warm up

9. 9 Fever cases in Phuentsholing, 2003 What is to be seen?  Smaller peak in the number of blood smears requests at the end of 2003  Peak seem in excess to what was usually seen in this season, but this is less obvious What to do?  The increase in the number of fever cases suggests an outbreak that needs to be investigated  In fact there was an outbreak of Plasmodium falciparum malaria Warm up

10. 10 Number of slides tested for malaria in Phuentsholing, Bhutan, 2001-2004 0 100 200 300 400 500 600 13579 111315171921232527293133353739414345474951 Weeks Number of slides tested for malaria 2004 2003 2002 2001 The 2004 Dengue outbreak was detected A 2003 falciparum outbreak was missed Warm up

11. 11 Take home message from this example All the data is there  Only a lively surveillance system that collects, compiles, transmits and analyzes the data can lead to useful public health decisions The better the system works, the better it will react  If the system is weak, it will only react to large signals (e.g., the 2004 Dengue outbreak)  If the system is strong, it will also react to more subtle signals (e.g., the 2003 Plasmodium falciparum outbreak that had been missed) Make surveillance operational and lively in your district! Warm up

12. 12 The essence of surveillance What is the disease?  How many get them? Time, place and person  Who get the disease?  Where they get them?  When they get them? Why they get them? What needs to be done as public health response? Info for action

13. 13 A functional vision of surveillance 1. Collect and transmit data 2. Analyze data 3. Feedback information 4. Make decisions All levels use information to make decisions Info for action

14. 14 Questions to address to set up a surveillance system 1.What is the objective of the programme served by the surveillance system? 2.What kind of decisions need to be made? 3.What information will be needed? 4.What indicators will be needed? 5.What data will be needed? Info for action

15. 15 Questions to address to set up a surveillance system: Cholera example 1.What is the objective of the programme served by the surveillance system? Detect cholera outbreak early 2.What kind of decisions need to be made?  Investigations and control 3.What information will be needed?  Sudden rise in incidence 4.What indicators will be needed?  Baseline incidence rates to detect unusual rates 5.What data will be needed?  Number of new cases per week Info for action

16. 16 Information for action The surveillance system is thought and operated from the point of view of the decisions that need to be taken Info for action

17. 17 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 District surveillance committee Superintendent of hospitals DSU

18. 18 District surveillance officer Accountant Administrative assistant Data entry operators (2) Response team Epidemiologist Microbiologist Clinicians Chief medical and health officer District surveillance unit DSU

19. 19 Epidemiologist (Nodal officer)* District administration nominee Support Staff: Entomologist** Health assistants Laboratory technician Clinician (Pediatrician/ Physician) Microbiologist * Selected from programme officers other than district surveillance officer, based on disease ** Only when vector borne disease is suspected District epidemic investigating team (DEIT) DSU

20. 20 Information flow of the weekly surveillance system Sub-centres P.H.C.s C.H.C.s Dist. hosp. Programme officers Pvt. practitioners D.S.U. P.H. lab. Med. col. Other Hospitals: ESI, Municipal Rly., Army etc. S.S.U. C.S.U. Nursing homes Private hospitals Private labs. Corporate hospitals DSU

21. 21 Functions of the district surveillance unit Managerial  Implement and monitor all project activities  Coordinate with laboratories, medical colleges, non governmental organizations and private sector  Organize training and communication activities  Organize district surveillance committee meetings Data handling  Centralize data  Analyze data  Send regular feedback Outbreak response  Constitute rapid response teams  Investigate DSU

22. 22 Interactive session: What functions of the district surveillance unit are in place in your district? Review the functions of the surveillance unit at the district level one by one All participants in the class take turn to say if this specific function is operational in their district DSU

23. 23 Interactive session: What functions of the district surveillance unit are in place in your district? Managerial  Is the unit implementing / monitoring all project activities ?  Do laboratories, medical colleges, non governmental organizations and private sector report in your district?  Was IDSP training completed as per recommendations?  When did your district surveillance committee meet last time? Data handling  Does the district centralize data?  Does the district analyze data by time, place and person?  Do you send regular feedback containing data? Outbreak response  Do you have a rapid response team?  When was the last time the district Investigated an outbreak? DSU

24. 24 Key elements of a surveillance system that need to be in place Regular and timely collection of data  Case definition, forms, reporting units Compilation of data  Aggregation of cases Analysis of data  Calculation of rates, time place and person analysis  Graphs and tables Interpretation of data  Conclusions Feedback of information  Recommendations Action Starting up!

25. 25 The role of the district within the surveillance system CompilationAnalysis Feedback District State Reporting units Action Data are compiled before they are passed on Starting up!

26. 26 Interactive session: How would you address obstacles to passive reporting in a district 1.What are the obstacles to data collection? 2.What are the obstacles to data compilation? 3.What are the obstacles to data transmission? 4.What are the obstacles to data analysis? 5.What are the obstacles to review by committee 6.What are the obstacles to using surveillance information to make decisions? Starting up!

27. 27 Interactive session: How would you address obstacles to passive reporting in a district Break down in 6 groups Each group select one of the key function of the surveillance system Participants list the most important obstacles to this function in their district Participants identify solutions to the obstacles identified Starting up!

28. 28 Example: Data collection Obstacles  Medical officers do not write the diagnosis in the registers Solution  Phase in IDSP register with diagnoses Starting up!

29. 29 Obstacles and possible solutions to initiate passive reporting (Fill with feedback from the groups) ActivitiesLocksKeys Collection … … Compilation … … Transmission … … Analysis ….. Review Action … … Starting up!

30. 30 Take home message 1.Give life to your surveillance system 2.Design surveillance to make decisions 3.Implement the functions of the district surveillance unit 4.Identify and lift obstacles to initiation of passive surveillance

31. 31 Additional reading Section 1 of IDSP operations manual Module 2 and 4 of training manual Annexure 4 and 5 IDSP guidelines