Presenter - Dr. Prateek Singh Moderator - Dr.

Panna Lal

Introduction Surveillance- definition and elements & need of surveillance. IDSP?

Aims and objective Core conditions Administrative structure DEIT Reporting formats Monitoring and evaluation

SWOT analysis

y The burden of disease in India is one of the highest in the

world. y Triple burden of infectious diseases. 1. Those infectious diseases that are prevalent & for which preventive measures are not yet available. 2. Diseases that are prevalent because of insufficient public health measures. Industrialized nations have controlled with the efficient application of the principles of public health. 3. Diseases perpetuated by the prevalence of vectors as well as vertebrate fauna, and the ecological determinants which are specific to our geo-climatic features.

Non-infectious diseases tend to be multi-factorial and are therefore, less amenable to control measures.

Planning for disease prevention and control depends upon the disease epidemiology, that can be made available through proper surveillance.

Defined as the ongoing systematic collection, collation, analysis and interpretation of data and dissemination of information for public health. -Without action data collection is not surveillance. -Activities related to case management of affected patients even though important for public health system is not surveillance activity.

1. Early recognition of cases or cluster of cases. 2. Assess the public health impact of health events or determine and measure trends. 3. Demonstrate the need for public health intervention programmes & resources & allocate resources during public health planning 4. Monitor effectiveness of prevention & control measures. 5. Identify high risk groups or geographical areas. 6. Develop hypothesis that lead to analytic studies about risk factors for disease causation, propagation or progression.

y Detection & notification of health event. y Investigation & confirmation (epidemiological, y y y y

clinical, laboratory). Collection of data. Analysis & interpretation. Feedback and dissemination of results. Response for prevention and control.

Success of surveillance upon 3R y Recognition. y Reporting y Response.

y De-centralized, state based surveillance y y y y

programme. Launched in November 2004 with world bank assistance. Initially CSU located at Nirman Bhavan Shifted to NICD(now called NCDC) in 2006. Intended to detect early warning signals of impending outbreaks & help initiate an effective response in a timely manner.

1. To establish a de-centralized district based system of surveillance for communicable and noncommunicable diseases so that timely & effective public health actions can be initiated in response to health challenges in the urban & rural areas. 2. To integrate existing surveillance 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.

1. Integrating & decentralizing disease surveillance & response mechanisms 2. Strengthening Public Health Laboratories 3. Using Information Technology and Networking in disease surveillance 4. Human Resource Development 5. Operational activities and response 6. Monitoring and evaluation.

Phase I (2004-05): Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh, Uttaranchal, Himachal Pradesh & Mizoram (nine states); Phase II (2005-06): Chhattisgarh, 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, Lakshadweep.

y Regular surveillance. y Sentinel surveillance. y Regular periodic surveys.

y Vector borne disease- Malaria y Water borne disease- Acute Diarrhoeal y y y y y y

Disease(cholera), Typhoid Respiratory disease- Tuberculosis Vaccine preventable diseases- Measles Disease under eradication- Polio Other conditions- Road Traffic Accidents, Other international commitments- Plague, Yellow fever Unusual clinical syndromes (causing death/ hospitalisation) Meningoencephalitis/Respiratory Distress, Hemorrhagic fevers, other undiagnosed conditions

y Sexually transmitted diseases- HIV/HBV, HCV y Other conditions- Water quality, Outdoor air

Quality

y NCD Risk factors- Anthropometry, Physical

Activity, Blood Pressure, Tobacco, Nutrition

y State specific diseases- Dengue, Japanese

Encephalitis, Leptospirosis

y IDSP function independently at the district level. y The ownership of the programme is at the state level y At national level CSU will provide technical support,

and guidance along with financial support

y At National, State & District levels IDSP primarily has two y

y y y

bodies: Surveillance committee & Surveillance Unit. The Committee would be a body for taking policy & strategic decisions, monitoring & coordinating with stakeholders. The Unit would be responsible for implementing various activities envisaged under the Project. Focal point of all surveillance related activities at the periphery would be the District Surveillance Unit. DSU will receive data from both urban and rural reporting units.

District Surveillance Committee

District Program Manager Polio, Malaria, TB, HIV - AIDS CMO (Co. Chair) Representative Water Board

Chief District PH Laboratory

Superintendent Of Police

District Data Manager (IDSP)

IMA Chairperson* Representative District Surveillance Committee NGO Representative

Representative Pollution Board

District Training Officer (IDSP) District Panchayat Chairperson

Medical College Representative if any District Surveillance Officer (Member Secretary)

* District Collector or District Magistrate

y District surveillance officer (DSO) y Data manager y Data entry operator y Accountant y Class IV

y There are 3 parallel systems of surveillance that will be

established 1. Syndromic- paramedical personnel community member 2. Presumptive- medical officer 3. Confirmed lab based

Rural Surveillance

CSU

Urban Surveillance

SSU
District HIV/AID
Rural SSPS15 PHC Subcenters Informers

District TB lab
ESI Railway hosp Water dept CGHS Corporation Hosp District hospitalsPollution ICMR lab

DSU

Rural medical colleges

Police

Medical colleges

Urban SSPS

District malaria

y DEIT is multifaceted team that looks into the various

aspects of an outbreak. y There will be a DEIT team at each district. y DEIT will investigate each and every outbreak to reveal why the outbreak occurred, identify the high-risk groups and areas and evaluate control measures.

1. 2. 3. 4. 5. 6.

Nodal officer The clinician The microbiologist District administrative nominee.(not below the level of tahsildar) Any other person in the list of surveillance consultants with DSO. The health assistant.

Public health sector Rural CHCs, district hospital

Private health sector Sentinel private practitioners & sentinel hospitals Sentinel private nursing homes, sentinel hospitals, medical colleges, private and NGO labs.

Urban

Urban hosp, ESI/railway/medical college hospitals

y Sub-center- health worker/ ANM reports all the

patients fulfilling the clinical syndrome from PHC, private clinic, hospital etc.
y PHC- medical officer reports all the probable cases of

interest where this can not be confirmed by lab tests at the peripheral units and as confirmed when the lab info is available as in case of blood smear positive malaria and sputum AFB +ve Tuberculosis.

y Other sentinel sites

ANC sites NACO- HIV/HBV/HCV Surveillance water board, Pollution control board, District police office for road traffic accidents.

y MO of PHC will report weekly on MONDAY to CHC . Hard

copy of form A & form L will also be sent from PHC to CHC once weekly. y Zero reporting is mandatory. y The mode of transmission will be in any of the following methods: -letter -fax -Telephone -Direct courier.

y The designation of the person responsible for data

compilation and transmission at each level is identified below:  PHC- pharmacist  CHC- computer/ pharmacist  Sentinel private practitioners (SPPs)- Medical officer  District hospital- Computer/ pharmacist  Medical college- Statistical officer  Laboratory- MO incharge/ lab technician.

y DATA ANALYSIS SHOULD IDEALLY BE DONE AT

EACH LEVEL y But the main people responsible for analysis are:  DSO- for rural areas.  Corporation health officer- urban areas

No. Reports 1 2 3 4 5 6 7 Timeliness & completeness of reports Description by time, place & person Trends over time Checking for crossing of threshold levels Comparison between reporting units Comparison between public & private Comparison between disease and lab data

Daily 1

Weekly

Monthly Yearly

Integrating private practitioners in surveillance. (SPPs)

Objective: 1. to identify disease outbreaks early. 2. to find out trends of disease over a period of time. The DSO will be responsible for integrating SPPs in each district. Selection criteria:  Willingness to participate.  SPPs who are likely to come across a large no. of cases of disease of interest.  Previous experience with collaboration on health programme with the public health system.

y They are currently not contributing effectively to

surveillance activities in the country. y The following depts. In the college will be the sites for reporting the diseases under surveillance.  Principal/ medical suprintendent(chair)  Community medicine  Medicine  Pediatrics  Chest and tuberculosis  Microbiology  Cardiology

y In addition to data collection medical colleges

can contribute to the IDSP as  Reference laboratory  Quality assurance  Training  Epidemic investigation  NCD surveillance

y Health workers enjoy a good relationship with their

communities and are in regular contact with village elder s particularly ladies, pradhan panchayat members, chauwkidar, and other community members who tell them about the occurrence of disease.
y All these individuals and organizations are identified as

community stakeholders

y Rural areas

Panchayat and its members; school teachers; community based organisations e.g mahila mandals & youth clubs; NGOs; elected representatives from the area; private rural practioners.
y Urban areas

Municipal councilors; representatives of professional bodies e.g. IAP, IMA, API; NGOs; chemists organizations; leading private practitioners & owners of hospitals and nursing homes.

y Following risk factors will be measured under IDSP :

Tobacco 2. Alcohol 3. Raised BP 4. Obesity 5. Diet 6. Physical activity 7. Diabetes Mellitus 8. High serum cholesterol In addition demographic(sex, urban/rural residence), socio-economic variables(education, occupation, income), past and family history of cardiovascular diseases, diabetes, and hypertension will be measured
1.

y A pre-tested simple questionaire has been prepared for

carrying out the survey. These questionnaires has already been developed by WHO(STEPS) modified for the Indian scenario and is already in use for sentinel surveillance for cardiovascular risk factors in 10 selected industrial population all over india

y A practical physiological consideration is that since

survey requires the participant to fast overnight it would commence early in the morning and finish early in the afternoon (6:00 am to 1:00 pm). The staff can utilize the rest of the day in coding the forms, dealing with lab specimens and other documentation.

METHODS
y Both formally and informally y Formal methods:
 Newsletters.  Monthly review meetings.  Informal feedback .  Electronic communication.

y Needed for high quality of surveillance. y It should be constant and supportive to motivate the y
  

staff. INDICATORS Weekly Monthly yearly

y Timeliness of reports. y Completeness of reports.

Apply for all levels and in both urban and rural settings

y Completeness of report for the period XXXX

no. of reporting units that have been complete during the specified period

Total no. of reporting units

y Timeliness of report for the period XXX

No. of reporting units that have been on time during the specified period Total no. of reporting units

y % of outbreaks that have been detected

No. of outbreaks detected by the surveillance system Total no. of outbreaks during that period

y Completeness of report for the year y Timeliness of report for the year y Percentage of outbreaks that have been detected y Percentage of newsletters published

y INPUT INDICATORS o % of staff at each level trained of reporting units at

each level with functioning computers o % of reporting units using case definitions o % of districts with functioning RRTs o % of districts with functional labs.

o Percentage of outbreaks that have been detected o Percentage of outbreaks have been detected within o o o

one incubation period. Percentage of outbreaks have been confirmed Percentage of outbreaks have been investigated Percentage of outbreaks have been investigated within 48 hours of detection Percentage of outbreaks have a CFR within the accepted norms.

o Proportion of lab specimens received in good

condition. o Proportion of lab specimens received with properly completed lab forms. o Proportion of lab specimens results reported within seven days after receipt of specimens in the lab.

y Integration of different stakeholders from community. y De-centralised state based approach y NIC has already installed the data center equipments at

most of the sites(776/800 sites) for speedy online transmission of data. y Training center equipments (378/400 by NIC & 367/400 by ISRO) for managing live virtual classroom for training, interactive electronic discussion and monitoring of project related activities. y Training of state/district surveillance team have been completed for 28 states and UT and partially completed in 3 states y 24*7 call center has been established for receiving disease alerts from all over India. toll free number 1075

y Indicators have been made for monitoring and

evaluation of the ongoing activities y Reporting format has been designed in simple and easy way. y Broadband services is provided by BSNL which has country wide network.

y SHORTNESS OF TRAINED MANPOWER LIKE

ENTOMOLOGIST(17/35 STATES), EPIDEMIOLOGIST. y OUT OF PROPOSED 50 LABORATORIES ONLY 26 (IN 18 STATES) LABS HAVE COMPLETED THE PROCEDURE OF PROCUREMENT. y NO INCENTIVE IS GIVEN FOR THE

y INDIA IS LEADING COUNTRY IN TRAINED IT

PROFESSIONALS y TAPPING THE POTENTIAL OF VAST NETWORK & COVERAGE OF MOBILE USAGE FOR RAPID TRANSFER OF DATA THROUGH sms ESPECIALLY IN POORLY ACCESIBLE AREAS .

y INCREMENTAL OPERATIONAL COST FOR

MAINTENANCE OF EQUIPMENTS, COMPUTER HARDWARE ACCESSORIES, VEHICLES ETC. y MAJOR FUNDING IS FROM EXTERNAL SOURCES. y 70% OF HEALTH CARE IS PROVIDED BY THE PVT HEALTH SECTOR.

y IDSP training manual for state and district surveillance y y y y

officers, 2nd edition Feb. 2006 IDSP operational manual for district surveillance unit. Brief note on IDSP, December 2010 issued by national centre for disease control (DGHS). J. Kishore s National Health Programs Of India, 9th edition. D.K. Taneja, Health policies and programs in India, 9th edition