dr.s krishnan

8/2/2019 Dr.S krishnan

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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 (healthbeing a state subject)

Many gaps, differed in degree and qualityof surveillance, different priorities in

diseases Rapid Response Teams (RRTs)

(depending on the epidemic potential ofthese diseases) were called : - Malaria Response Teams

Cholera Combat Teams

Other disease specific Response Teams

Little / no information was madeavailable at National level


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National Health Programmes

Significant surveillance component

Disease 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 theimportance of Disease surveillanceafter the Cholera outbreak in Delhi

and the Plague outbreak in Surat,which not only had significantmortality and morbidity but alsosignificant economic consequences.


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National SurveillanceProgramme for Communicable

Diseases (NSPCD)

NSPCD was therefore launched by the

Centre in 1997-98 in five pilot districtsof the country (centrally sponsoredscheme) and over the years extended tocover 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 theimplementing agencies and NICDDelhi is the Nodal agency forcoordinating the activities.

This programme is based on outbreakreporting (as and when outbreaks

occur) with weekly reporting ofepidemic prone diseases directly fromDistricts (including nil reporting) tothe Centre.


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Main strategyTo establish Early Warning System (EWS) so as toinstitute appropriate and timely response for

prevention & control of outbreaks

Every state/UT and all the 101 districts has atrained multi-disciplinary Rapid Response Team

Rapid communications (through e-mails & fax)

Strengthening of state and district laboratoriesfor rapid confirmation of diagnosis

Capacity development of health staff in thedistricts

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 (20+1 districts*)

* The district of Shimla taken asa special case during 2002-03


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Diseases/pathogens covered

Epidemic prone communicablediseases- acute diarrhoeal diseasesincluding cholera, viral hepatitis,

dengue, Japanese encephalitis,meningitis, measles, viralhaemorrhagic 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 / districtlaboratories

Improving sub-district mobility and

communication


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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 NSPCDdistricts

during 2001, 2002 & 2003Jan - June


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Weekly reports received from NSPCDdistricts during 2001,2002 & 2003

July-Dec

0

10

20

30

40

50

60

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Week No.

No.o

freportsreceived

2001 2002 2003


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Monthly reports received during

2001, 2002 & 2003 from NSPCD districts43 42

40 39 39

34 35

30 30

27

32 31

41

38 39

45

42 4144

3537

39

31

3938 39 38 39

45

32 32

28

2326

18

46

05

10

15

20

2530

35

40

45

50

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Month

No.o

fReports

received

2001 2002 2003


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Month-wise outbreaks 2001,2002 & 2003

0

10

20

30

40

50

60

70

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Month

No.o

foutbreaks

reported

2001 2002 2003


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Profile of outbreaksinvestigated by NSPCD

districts

57

3 5 6 0

101 1

5 2 0 0

85

147 8 5 7 6 3 1 1 0 0

105

80

6 37 9

1 25 2 2

0

20

40

60

80

100

120

ADD

(GE,Diarrhoea,

Dysen

try)

M

alaria

JE

Measles

Food

Poisoning

Chick

enpox

Type of outbreak

No.ofo

utbreaks

2001 2002 2003


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Laboratory strengtheningDistrict laboratories

WATER + STOOL C/S

WATER ONLY

NO WATER; NO STOOL C/S

NO INFORMATION

NON NSPCD DISTRICTS


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Investigations performed atNSPCD district laboratories

Microscopy:

Wet mount for cholera, T/S for diphtheria, AFBsmear, smear for plague bacilli, P/S for MP, P/S forMf, BMA for LD bodies, CSF for Pyogenicmeningitis.

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 s ecialized serolo .


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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, SCBMedical College Cuttack, etc

In District RRTs-Medical CollegesKottayam, Khozikode, Calicut,Alappuzha, Dibrugarh, Silchar, etc

As Regional/District Labs- MedicalColleges Gwalior, Kolar, Bellary, Shimla,Ahmedabad, Kakinada, Silchar,Dibrugarh, etc


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Monitoring of the programme

Review meetings- regionalmeetings half yearly in 2001,2002, 2003

Field visits by expertsthroughout the year

Independent Appraisals carriedout in 2001 and December 2003


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Achievements

1. Improved quality of detection,

investigation and response to

outbreaks

2.

Rapid Response Teams with requisiteknowledge and skills in place

3. Technical material on outbreaks

investigation, manual on laboratoryprocedures and computer usage

developed and made available in field


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Achievements4. 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)


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NSPCDNSPCD has significantly improved the

capacity of these districts and statesto detect investigate and respond tooutbreaks, yet

It was not case based reporting anddid not give a complete picture ofdisease burden in the countryespecially in respect of epidemic

prone diseases GoI not convinced to expand this

programme to all districts in thecountry


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Integrated Disease SurveillanceProject (IDSP)

Integrated Disease Surveillance

Project (IDSP) was conceptualizedand proposed and the GoIapproached the World Bank for thenecessary funding


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Objectives of IDSP

Establish a decentralized system ofdisease surveillance for timely andeffective public health action

Improve the efficiency of diseasesurveillance for use in health

planning, management andevaluating control strategies


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IDSPBased on case based reporting

Syndromic surveillance (suspectcase reporting at PHC and below)

Confirmed case reporting ofselected priority diseases (at

district level)

Passive reporting of Road Traffic

Accidents and Air Pollution.


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Syndromic surveillance

Fever7 days

Cough>3 weeks

AFP

Diarrhea

Jaundice

Unusual events causingdeath/hospitalization


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Target diseases

Malaria

ADD(Cholera)

Typhoid Tuberculosis

Measles

Polio Plague

HIV, HBV, HCV

UnusualSyndromes

Accidents Water Quality

Outdoor Air

Quality NCD Risk factors

State Specific

Diseases


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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 & NHaveli, Daman & Diu, Lakshwadeep.


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Organizational Structure

Disease Surveillance Committee

Executive Committee

Disease Surveillance Unit

District Surveillance Committee


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District Surveillance Committee

Chairperson*District Surveillance Committee

District Surveillance Officer(Member Secretary)

CMO(Co. Chair)

RepresentativeWater Board

SuperintendentOf Police

IMARepresentative

NGORepresentative

District PanchayatChairperson

Chief District PHLaboratory

Medical CollegeRepresentative

if any

RepresentativePollution Board

District Training Officer(IDSP)

District Data Manager

(IDSP)

District Program ManagerPolio, Malaria, TB, HIV - AIDS

* 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 CENTRESPHCs/CHCs

RURAL PPs


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Formats & manuals

Standard Case Definitions

Standard Formats for reporting

Operations manual for HealthWorkers, Medical Officers, LaboratoryTechnicians and District/State

Surveillance Teams

Standard user friendly trainingmanuals


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NCD risk factor surveillance

Monitor trends of important risk

factors of NCD in the communityover a period of time

Evolve strategies for interventions

of these risk factors so as toreduce the burden of diseases dueto NCDs

Strengthen NCD surveillance atDistrict level

Integrate NCD risk factorsurveillance with IDSP


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Strengths of IDSP

Functional integration of surveillancecomponents 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 reportingformats

Streamlined flow of funds to thedistricts


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Integration

National programmes

NCDs

Private sector

Police, PCBs, Water supply

IEC activities

Training

Formation of committees to overseeintegration


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Integration ?!

What exactly do we expect inintegration

Functional integration to what degree

Vertical programmes will continue NCD component invariably stand

alone

IEC, Training, Formats- consultationwith these programmes

Fund sharing a daunting task


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Disease Surveillance

Lessons learnt / Issues

l


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Lessons learntNSPCD 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 feedbackplanned 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 onCentre-state relations

Central assistance proportionate topolitical affiliations

Media attention an importantconsideration for response

Time constraints-inadequate time

given for outbreak investigation Hesitancy for international assistance

either in Outbreak Investigation orLab support


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National Issues contd

Reduced attendance in public healthsystem and increased in privatesector almost 40:60 or more

Wide-spread quackery in the name ofalternate medicine (ayurveda, unani,homeopathy, etc)

Overworked clinicians so poormaintenance of medical records likecase sheets/prescriptionslips/provisional diagnosis/etc

Lack of ownership by states of centralvertical programmes

St t i


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State issues State RRT not utilized to full potential

Regional labs strengthened but labdiagnosis not enhanced & increasingdependence on Centre

Insufficient epidemiological analysis No clear IEC strategy

Frequent transfer/retirements of trainedstaff so programme invariably suffers

Shortage of staff so multi-tasking for stateand district level functionaries.

Fund issues and Utilization certificates


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State issues contd

Lack of competent staff especiallyPublic Health Professionals andMicrobiologists in majority of the

states. Short trainings not likely tobuild the necessary capacity.

Clear demarcation between theDirectorate of Health Services and

Directorate of Medical Education sodifficulties in integrating Medicalcolleges

Di t i t i


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District issues

Programme is focused on district epidemic

preparedness and response but somedistricts yet to get their act together

Reporting from periphery needs

improvement. If media first reporting thenSURVEILLANCE FAILURE

Weekly reports incomplete and irregular(and under reporting)

Monthly reports also irregular (CBHI hasto increase its role & responsibility)

Communication failure

CMO-CMS-DSO lack of co-ordination

Di t i t i td


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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 composedof specialists from District hospital/Medical college and problem in rapidmobilization as from different agencies

Concept of Nil reporting/routine reportingdifficult for the peripheral staff tounderstand, compounded by lack offeedback from the higher levels

Di t i t l b i


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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 thatoverall district lab capacity enhanced


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Thank You

dr.s krishnan

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