Infectious

Disease
c e Surveillance
ll a n in
ve i
Su r India

Aneena Anna Abraham

Jithesh V
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Outline

1. What is Surveillance?
2. India and Infectious diseases
3. NSPCD
4. IDSP
5. DLDS - Kottayam
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Surveillance

Surveillance is the
ongoing
systematic collection
collation
analysis and interpretation of data
and
the dissemination of information to those who
need to know
in order that action may be taken
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Before starting Surveillance

 Is the disease of public health importance?

 Is it worth the effort (money, human resources)?
 Are relevant data easily available?
 Can action be taken based on surveillance?
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Objectives of surveillance
 Monitoring disease trends
 Estimating magnitude of health problems
 Epidemic (outbreak) detection and prediction
 Estimating future disease burden
 Understanding characteristics of health events
• Distribution and spread
• Natural history
 Evaluating an intervention, especially control
programmes
 Facilitate planning
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Types of surveillance

 Passive surveillance: Data routinely collected and

forwarded
 Active surveillance: Data actively sought out by visiting
or contacting a reporting site
 Sentinel surveillance: Only selected sites report data.
(This is rarely representative of the population but can
be used to monitor trends and collect more detailed
information)
 Laboratory surveillance: Based on laboratories
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Steps in planning a surveillance system
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 Establish objectives
 Develop case definition
 Identify data source and data collection mechanism
 Develop data collection instrument
 Field testing of methods
 Develop and test analytic mechanism
 Develop dissemination mechanism
 Mechanisms to ensure use of analysis and interpretation
 Evaluation
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India

 Estimated population of 1.15 billion in 2010

 20% of world’s population on only about 2.5%
of its surface area
 Adds on an average about 22 million newborns
to its population every year
 High population density (312 people/sq. km.)
 325 recognized languages
 Health is a state subject
 Large number of vertical programmes
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Health Transition in India

Persisting Emerging Emerging

CDs NCDs Infections
Adapted from: Dr. D.C.Jain; Disease Surveillance in India; NICD 2006
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Changing scenario of
il l a
Sur
ve
Communicable diseases in India

HIV / AIDS
Dengue Poliomyelitis
HIV TB co-infection Tuberculosis
Japanese Encephalitis Neonatal Tetanus
Leptospirosis Measles
MDR Infections
Eradicated Smallpox, Guinea worm disease
Eliminated Yaws
Emerging Avian Influenza, Nipah, H1N1, etc
Adapted from: Dr. D.C.Jain; Disease Surveillance in India; NICD 2006
 e
The Government of India realized the
anc
eill
Sur v importance of Disease surveillance after:

 Cholera outbreak in Delhi, 1988

 Plague outbreak in Surat, Gujarat 1994
• significant mortality and morbidity
• significant economic consequences
 l l an ce National Surveillance Programme
ur vei
S
for Communicable Diseases
(NSPCD)
 Launched in 1997-98 in five pilot districts of
the country (centrally sponsored scheme)
 Extended over the years to cover 101
Districts in the country in all States and UTs.
 States were the implementing agencies and
NICD (Delhi) was the Nodal agency for
coordinating the activities.
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NSPCD

 Programme was based on outbreak reporting

(as and when outbreaks occur)
 Weekly reporting of epidemic-prone diseases
directly from Districts (including nil
reporting) to the Centre.
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NSPCD - Strategies
 Early Warning System (EWS): To institute
appropriate and timely response for prevention &
control of outbreaks
 Rapid Response Team: A trained multi-disciplinary
RRT in every state/UT and all the 101 districts.
 Rapid communications: Through e-mails & fax
 Strengthening of state and district laboratories: for
rapid confirmation of diagnosis
 Capacity development of health staff in the districts
 IEC (Information Education and Communication)
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Diseases/Pathogens covered
 Epidemic prone communicable diseases-
• Acute diarrhoeal diseases including cholera
• Viral hepatitis
• Dengue
• Japanese encephalitis
• Meningitis
• Measles
• Viral haemorrhagic fevers
• Leptospirosis, etc.
 Pathogens with bioterrorism potential
 Drug resistant pathogens
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Expected outcomes

 Early detection of outbreaks

 Early institution of containment measures
 Reduction in morbidity & mortality
 Minimize economic loss
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Outcomes achieved

 Improved quality of detection, investigation

and response to outbreaks
 Rapid Response Teams with requisite
knowledge and skills in place
 Technical material on outbreaks investigation,
manual on laboratory procedures and
computer usage developed and made available
in field
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Outcomes achieved ….

 Training in computer application for data processing

and communication
 Feedback mechanism in the form of “Outbreak News”
& “CD Alert” and by frequent letters through e-
mail/post
 Improved capability of laboratories for etiological
diagnosis
 Rapid transmission of information
 NICD Website www.nicd.org (includes NSPCD
networking)
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Feedback mechanisms

ly h ly
e e k ont
W M
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Drawbacks

 Not case based reporting

 Only outbreaks reported
 Did not give a complete picture of disease
burden in the country
 GoI dropped plans to upscale this programme
to all districts in the country
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Weaknesses in
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ve
Surveillance system

 Lack of integration of private care facilities

 Poor lab capacity
 Blind spots in urban areas
 Slow & inefficient sharing of information at all
levels
 Limited capacity for analysis and action at District
level
 Non inclusion of NCDs in surveillance
programmes
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IDSP

Integrated
Disease
Surveillance
Project
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IDSP

 Launched in 2005
 Decentralised programme with District as the
hub
 Case based reporting
 CD & NCD and their risk factors
 Integration with surveillance mechanisms of
other National Programmes
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IDSP

 Phase I
 Madhya Pradesh, Andhra, Himachal, Karnataka, Kerala,
Maharashtra, Mizoram, Tamil Nadu & Uttaranchal
 Phase II
 Chattisgarh, Goa, Gujarat, Haryana, Orissa, Rajasthan, West
Bengal, Manipur, Meghalaya, Tripura, Chandigarh,
Pondicherry, Nagaland, Delhi
 Phase III
 UP, Bihar, J&K, Punjab, Jharkhand, Arunachal, Assam, Sikkim,
A&N Island, D&N Haveli, Daman & Diu, Lakshadweep
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Objectives of IDSP

 Establish a decentralized system of disease

surveillance for timely and effective public
health action
 Improve the efficiency of disease surveillance
for use in health planning, management and
evaluating control strategies
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Integration! What’s new?

 Sharing of Surveillance information among

Disease Control Programmes
 Developing effective partnerships among health
& non-health sectors
 Inclusion of both CD & NCD
 Effective partnership of Pvt sector and NGOs
 Inclusion of academic institutions in primary
public health activity
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Classification of surveillance

 Syndromic: Diagnosis made on the basis clinical

pattern by paramedical personnel and members of
community
 Presumptive: Diagnosis is made on typical history
and clinical examination by medical officers
 Confirmed: Clinical diagnosis by medical officer
and or positive laboratory identification
Passive reporting of Road Traffic Accidents and Air
Pollution
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Syndromic surveillance
il l a
Sur
ve
(for Health Workers)
 Fever<7 days
• Alone
• With rash
• With altered sensorium/convulsions
• With bleeding skin/gums
 Fever>7 days
 Cough>3 weeks
 AFP
 Diarrhoea
 Jaundice
 Unusual events causing death/hospitalisation
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IDSP Components

 Integrating & decentralising disease surveillance

& response mechanisms
 Strengthening Public Health Laboratories
 Using Information Technology and Networking
in disease surveillance
 Human Resource development
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Project Activities
Renovation & Furnishing of Labs
Upgradation of Supply of Lab Equipments
Laboratories Lab. Material and Supplies

Information Computer Hardware & Office Equipments

Technology and Software for surveillance
Communication Leasing of Wide Area Networking
Consultant /contract staff
Human Resources Training
Development
Information Education & Communication
Operational Activities & Response
Monitoring & Evaluation
 vei
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Type of disease Disease

Vector borne diseases Malaria
Diarrhoea (Cholera)
Water borne diseases
Typhoid
Respiratory diseases Tuberculosis
Vaccine preventable diseases Measles
Disease under eradication Polio
Other conditions Road traffic accidents
International commitment Plague
Meningo-encephalitis
Unusual syndromes Respiratory distress
Hemorrhagic fever
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Type of surveillance Categories Conditions

 STDs HIV/HBV/HCV

Sentinel surveillance Water quality

 Other conditions
Outdoor air quality

Anthropometry

 Non communicable Physical activity

Regular surveys
disease risk factors Blood pressure

Tobacco, blood pressure

Nutrition
Others
Blindness

Additional State priorities Up to five diseases

 ur vei
l l an ce Structural Framework
S

Central Surveillance Unit

State Surveillance Unit

Medical Colleges
Dt. Hospitals
Pvt. Hospitals District Surveillance Unit
Other Hospitals
Laboratories

Peripheral Surveillance Unit

(Subcentre , PHC, CHC)
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Adapted from: IDSP – An overview; WHO-NICD 1997

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Level of Responses

Trigger-1 Response Health Workers

Trigger-2 Outbreak Inv. & Response

(PHCs/ CHCs)

Trigger-3 Outbreak Inv. & Response

(DSU)

Trigger-4 Epidemic Response

(SSU)

Trigger-5 Disaster Response

(CSU)
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IDSP - Strengths

 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
 Training manuals follow activities as described in
the operations manuals
 Formats & manuals translated in local languages
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IDSP - Strengths

 Functional integration of surveillance components

of vertical programmes
 Reporting of suspect, probable and confirmed
cases
 Strong IT component for data analysis
 Preset trigger levels for gradated response
 Action component in the reporting formats
 Streamlined flow of funds to the districts
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IDSP – Achievements so far

 ISRO connects all sites in northeastern states, hilly

and island states, Tamil Nadu, Gujarat, and
Maharashtra through its Education Satellite
(EDUSAT)
 The National Informatics Centre (NIC) has
provided terrestrial (broadband) connectivity to
776 of the 800 sites.
 High-end video conference equipments at all
state and Union Territory headquarters.
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IDSP – Achievements so far
 IDSP portal (www.idsp.nic.in)
 Media Scanning and Verification Cell
 24x7 call centre with a toll free number (1075) to
receive disease alerts
 85% of districts are reporting weekly data to IDSP
promptly
 Video conferencing
 Distance learning
 Use of communication network during the H1N1
pandemic
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Practical issues

 Low involvement of private sector reporting

 Strengthening skills for data use and analysis at
all levels
 Enhancing the convergence of ICT with other
national health programmes
 Improving media scanning and verification
 Making data transmission all-inclusive by
incorporating, mobile, text, voice, email and fax.
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DLDS

District Level
Disease
Surveillance
Kottayam
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DLDS
A disease surveillance model developed in the North Arcot district, Tamil Nadu with
district as the surveillance unit

1980s Pre-formatted, printed, self-addressed post cards with affixed postage stamps used for
reporting cases

Monthly disease summary bulletin -‘NAD health information’ or NADHI for short

Suspected plague outbreaks in Maharashtra and Gujarat

Governmentof India (GoI)appointed a committee to identify the causes and

1994 recommend control measures to detect and control any future outbreaks of plague or
other communicable diseases

This committee recommended that the ‘NADHI model’ of disease surveillance should
be replicated in all districts of the country

MOHFW, Kerala decided to replicate this model with some modifications – pilot in one
1998
district and if found feasible, to expand it to all districts in a phased manner

July
DLDS Pilot project in Kottayam district – financial support from CMC, Vellore
1999
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Kottayam DLDS
 List of diseases finalised (Group of Drs from Govt Medical College,
TVM + Govt & Pvt hospitals)
 Pre-formatted business reply cards used (to avoid distribution of
postage stamps)
 Addressed to Dy. DMO(H) – Nodal Officer i/c of DLDS
 Training –
• All MOs of the local PHCs and CHCs
• All administrators or medical superintendents
• Physicians and paediatricians of all hospitals in the government and
private sectors in the towns and all nearby places
• DMO(H), Dy. DMO(H), supervisory staff in the office of the DMOH
 Manual detection of any clustering in time or space – investigation
by staff of health system
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Kottayam DLDS
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Disease Reporting Card
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Kottayam DLDS

 Doctors instructed to report the disease on the day of

clinical diagnosis - not to wait for laboratory confirmation.
• To compensate for the inevitable but short postal delay
• To prevent delays in reporting cases for lack of lab evidence
 Monthly bulletin containing summary reports of diseases,
outbreak alerts and other relevant information mailed to
every hospital in the district
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e
Kottayam DLDS
eill
Sur v
July 1999 to June 2001- Study Results
T. Jacob John, K. Rajappan, K.K. Arjunan. Communicable diseases monitored by disease
surveillance in Kottayam district, Kerala state, India. Indian J Med Res 120, Aug 2004, pp 86-93

 Most frequently reported diagnosis – acute dysentery

 Most common disease in the ‘any other’ category – leptospirosis
(the most frequently reported disease)
 No diphtheria, rabies, tetanus or whooping cough
 Nearly every disease, except encephalitis, showed obvious seasonal
variations
 Anticipated that no vaccine-preventable disease of childhood would
be occurring - measles was frequently reported
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Kottayam DLDS
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Sur Case Study – Cholera Outbreak (Jan 2000)
January 1  First post card reporting cholera received
 One report each on the next 5 days
se s ,
 Nodal officer informed of the isolation of Vibrio cholerae i s
O1e a
in te d
the sMicrobiology
January 6 Department of the Medical College r ic D gge
 DMOH conferred with the District CollectorEand n d su leaders
tedistrictnpanchayat a s
a n d g s a ra w
le ra d in o le o n
January 7 District was declared ‘cholera-affected’
h o fin f c h e nti
o f C h e i c o
t liaisonmcommittees e r v
District task force and
te panchayat
t e d
level
e i ntestablished
ti tu ti ga pi d
e warning e l y
I n
Intensive health
l s educationve s effortsuincluding
s tim against drinking water
n
without
o a boilingts n
i classes
(13,670 i o h e
t within atweek)
ti e r l am t o
NaChlorination
e x p r
o tedc a d u e in the district within a week
k a ta of
a j378,640 surface wells
Jan- Febo l
K Supply t a m v e r
t h a of oral y a
rehydration
l salts streamlined through opening 7120 new
distribution
b a b
points
pro
104 cholera among 1402 persons with acute gastroenteritis (Jan-Feb 2000)
Vibrio cholerae O1 isolated from stool samples of 30
8 deaths
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Other Outbreaks
 Four post cards reporting acute hepatitis in adult residents of one
panchayat
 Nodal officer arranged investigation by the local primary health centre
staff- 13 more unreported cases detected
 Families of all 17 affected persons used one source of water, a local well
August 1999  Use of water from it was prohibited
 Water was collected for testing
 Well was heavily chlorinated
 Water had heavy contamination with faecal coliforms

January 2001  5 post cards from one locality reported ‘ food poisoning’
 Investigation showed that over 100 persons attending a wedding party
were affected but none fatally
 Only the bridegroom’s relatives were affected, not the bride’s - As hosts,
the bride’s family had served but not taken the welcome drink of fresh
lemon juice.
 The caterer had used the easily available well water near the party hall -
the water was heavily contaminated with faecal coliforms
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DLDS
 Government accepted the first year’s performance of Kottayam
DLDS as satisfactory
 Replicated in two more districts – Alappuzha (2000) and
Ernakulam (2001)
 2001-2002 - DLDS extended to other districts
 October 2002 - all 14 districts in the State have established DLDS
 System was handed over to the state health department for
further management
 Based on the success of DLDS the government has agreed to
expand the role of the Kerala State Institute of Virology and
Infectious Diseases (KSIVID) to be the nodal centre to supervise
district level laboratories, to train personnel in microbiology and
epidemiology and to conduct outbreak investigations.
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Bouquets and brickbats

 Good cooperation from Doctors

 Ease of reporting motivated prompt reporting
 Many outbreaks averted
 Confidentiality of information?
 Postal delay in an era of ICT?
 Data used to full potential?
 Project handed over to Health department –
what then???
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In conclusion

 Systems are in place!

 How promptly are we reporting?
 How competent are we in using the data for
pro-active planning and implementation of
disease control measures?