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Transcript of 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