1.Dr. Abhishek Tiwari

2. Introduction Triple burden of infectious disease Worldwide : no specific preventive measure Due to insufficient Public Health Measure Prevalence of vectors & ecological determinants ID - More easily preventable than NCD Prevention & Control needs Surveillance To detect EWS of impending outbreaks & help allocate health resources efficiently 3. IDSP Decentralized project GoI in Nov 2004 ; World Bank funded 3 Phases : Extended for 2 years in March 2010 WB funds only for 9 states & CSU Domestic budget Continue during 12th Plan under NRHM 4. Objectives Establish a decentralized system of disease surveillance so that timely & effective public health action can be initiated Improve the efficiency of disease control programs & facilitate sharing of relevant information with various stakeholders so as to detect disease trends over time & evaluate control strategies 5. I D S P 6. Integration All National Disease Control Programmes Health & Non Health sectors (Police, PCBs, Water supply) Including NCD & CD Laboratory information Private sector & NGO Academic Institution & Medical Colleges IEC activities Training Formation of committees to oversee integration 7. Disease Identification of priority diseases : Target disease Malaria ADD(Cholera) Typhoid Tuberculosis Measles Polio Plague HIV, HBV, HCV Unusual Syndromes Accidents Water Quality Outdoor Air Quality NCD Risk factors State Specific Diseases 8. Surveillance Information:- Who got the dis? How many? From where? Why only them? What needs to be done as a Public . Health response? 9. Surveillance Strengthening hospital based surveillance Components Prerequisites Classification in IDSP Syndromic / presumptive / confirmed diagnosis Core condition under surveillance 10. Disease Surveillance Under IDSP 1. Regular Surveillance Vector Borne Disease : Malaria , Dengue ,JE , Filaria etc. Water Borne Disease : ADD (Cholera) : Typhoid Respiratory Diseases : Tuberculosis VPDs :Measles Diseases under eradication : Polio Other Conditions : Road Traffic Accidents Other International commitments : Plague Unusual clinical syndromes : Meningoencephalitis / DHF /other undiagnosed conditions 11. 2. Sentinel Surveillance STD/Blood borne : HIV/HBV, HCV Other Conditions : Water Quality / Outdoor Air Quality 3. Regular periodic Community Survey NCD Risk Factors : Anthropometry, Physical activity, Blood Pressure, Tobacco, Nutrition, Blindness 4. Additional State Priorities Each state may identify up to five additional conditions for Surveillance. 12. Syndromic surveillance Fever7 days Cough>3 weeks AFP Diarrhea Jaundice Unusual events causing death/hospitalization 13. Project components CSU integrated with NICD (NCDC) SSU & DSU in all states & districts Strengthening Public Health Laboratories Training of SSU/DSU/RRT (over in all states & UT) IT & Networking & HRD 14. Project Early detection of outbreaks Early institution of containment measures Reduction in morbidity & mortality Minimize economic loss A limited health condition & risk factor surveilled To involve all stakeholders private & public 15. 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, Rajasthan, West Bengal, Manipur, Meghalaya, Odisha, Tripura, Chandigarh, Po ndicherry, 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. 16. Formats & manuals Standard Case Definitions Standard Formats for reporting Operations manual for Health Workers, Medical Officers, Laboratory Technicians and District/State Surveillance Teams Standard user friendly training manuals 17. Organizational Structure National Surveillance Committee Central Surveillance Unit State Surveillance Committee State Surveillance Unit District Surveillance Committee District Surveillance Unit 18. 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 19. STRUCTURAL FRAMEWORK C.S.U. S.S.U D.S.U. P.S.U MED COL. DIST HOS. PVT. HOS. OTHER HOS. LABS SUB CENTRES PHCs/CHCs RURAL PPs 20. 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) 21. Performance Indicators Number & % of districts providing monthly surveillance reports on time by state and overall * Number & % of responses to disease specific triggers on time * # assessed to be adequate * # laboratories providing adequate quality of information * 22. Performance Indicators Number of districts : private sector contribution C/H/L Number and % of states integrating various programs Number and % of districts & states publishing annual surveillance reports Publication by CSU of consolidated annual surveillance report 23. IDSP Reporting Form S (Suspect Cases) by Health Workers (sub centres ) Form P (Probable Cases) by Doctors (PHC, CHC, Hospital) Form L (Lab Confirmed Cases) from Laboratories Frequency of reporting weekly (Monday to Sunday) Data compilation/analysis and response should be at all levels. Presently at State/District/Block level 12- 15 Outbreaks reported every week 24. Reporting units Sub-centre-health worker/ANM : All syndromic cases from PHC , clinic, hospital in the area PHC/CHC MO : Probable cases , where it cannot be confirmed by lab & those confirmed by lab (mp , afb ) Sentinel private practitioners , district hospitals ,municipal hospitals, medical colleges , sentinel hospital , NGOs : MO report as probable case of interest 25. New Initiatives under IDSP Alerts through IDSP call center : 1075 toll free February 2008 Call received as on 8th October 2008 : 18,872 No of Health Alerts : 60 26. e-learning To enhance skills of health personnel. Proposed components: Discussion Forums Online Survey & Assessment Feedback FAQs Currently e-learning modules are being prepared 27. Media Scanning Cell Objective: Supplemental information about outbreaks Method: National and local newspapers ,Internet surfing, TV channel etc screening for news item on disease occurrence Benefits Increases the sensitivity & strengthen the surveillance system Provide early warning of occurrence of clusters of diseases 28. Strengths of IDSP Functional integration of surveillance components of vertical programmes Reporting of suspect, probable and confirmed cases Strong IT component for data analysis Newer initiatives Trigger levels for gradated response Action component in the reporting formats Streamlined flow of funds to the districts 29. Lessons learnt NSPCD 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 feedback planned Strong IT component Strong state ownership (all districts) Fast financial flow Strong M & E, supervision Advocacy at all levels 30. National Issues Political considerations based on Centre-state relations Central assistance proportionate to political affiliations Media attention an important consideration for response Time constraints-inadequate time given for outbreak investigation Hesitancy for international assistance either in Outbreak Investigation or Lab support (plague) 31. National Issues contd Public health & private sector almost 40:60 Accountability of private sector on reporting Quackery in the name of alternate medicine Overworked clinicians so poor records Lack of ownership by states of central vertical programmes 32. State issues State RRT not utilized to full potential Regional labs strengthened but diagnosis not enhanced & increasing dependence on Centre Insufficient epidemiological analysis No clear IEC strategy Transfer/retirements of trained staff 33. State issues contd Shortage of staff so multi-tasking for state and district Fund issues Lack of competent staff : Epidemiologist & Microbiologists Short trainings incapable Separate DGHS & DME : integrating Medical colleges 34. District issues Some districts yet to act together : epidemic preparedness Periphery needs improvement Surveillance failure : media reports first Weekly reports incomplete and irregular (under reporting) Monthly reports also irregular Communication failure CMO-CMS-DSO lack of co-ordination 35. District issues contd Overworked peripheral staff Multiple formats for different programmes RRT has specialists from DH & MC so problem in rapid mobilization Concept of Nil reporting & routine reporting difficult for the peripheral staff to understand 36. District lab issues Few established & functioning satisfactorily Too Many labs spoil the agenda Public health lab : water Hospitals : NCDs and clinicals College : majority of the diseases Surveillance lab : few diseases District blood bank : ELISA Peripheral : Microscopy only 37. References J.Kishores National Health Programmes of India 10th Edition . century publications Parks Textbook of Preventive and Social Medicine , K. Park 22nd Edition . Bhanot Publishers Health Policies and Programmes in India , Dr. D. K. Taneja . 11th Edition . Doctors Publications IDSP website NRHM website NCDC website