Evolution /Development of Surveillance Systems (1999-2010) Dr Shashi Khare, Consultant ( Micro) National Centre for Disease Control New Delhi ,INDIA

India: Fact Sheet States : 35 (28 states & 7 UTs) Districts : 623 Villages : 638588 Towns : 5161 Total Population: 1.17 billion Total Area : 32,87,2631

Health transition in India COMMUNICABLE DISEASE EPIDEMICS 1950s onwards RAPID DEVELOPMENT (Scientific, urbanization & industrialization At present TRIPLE BURDEN Unfinished agenda of Communicable Diseases Emerging NCDs (Lifestyle diseases) Poor Public Health System Inequities Social, economic & political factors 3

Prologue Federal structure of governance Health is a State subject Prior to 1998, no centralized surveillance system States maintain its own list of notifiable diseases Supplemented by independent surveillance systems of various National health programmes (TB, Malaria, Leprosy) Central Bureau of Health Intelligence - National nodal agency for collection & documentation of health data

National Surveillance Programme for Communicable Diseases (NSPCD) Initiated in 1997-98 following recommendations of various High-powered committees Central Sector Health Scheme NICD as the nodal agency States/UTs as implementing agency Implemented in 101 districts spread over 28 States & 7 Union Territory’s, in a phased manner.

Districts covered under NSPCD

NSPCD - Broad Objective Strengthen surveillance system & improve capabilities of district & state: to identify & respond to outbreaks due to epidemic- prone diseases

Specific Objectives Establish early warning mechanism Effective use of surveillance data using rapid means for communication Institute appropriate & timely response for prevention & control of outbreaks Laboratory networking & strengthening for surveillance & rapid confirmation of diagnosis

NSPCD - Strategies Establish multi-disciplinary State/ Dist. RRTs Develop trained manpower Strengthen infrastructure incl. laboratories Develop rapid communication network Uniform & regular reporting Monitoring & evaluation Enhance awareness through IEC

Feedback Mechanism under NSPCD

Achievements Improved quality of detection, investigation and response to outbreaks Rapid Response Teams (RRTs) with requisite knowledge & skills in place Technical material on outbreaks investigation, surveillance & specific diseases, guidelines for RRT & manual on computer & laboratory procedures developed, made available in field Labs contributing in outbreak investigation

Achievements contd.. Training in computer application for data processing and communication Feedback through “Outbreak News” & “CD Alert”, frequent e-mails/post Improved capability of laboratories for etiological diagnosis NICD Website www.nicd.org (includes NSPCD networking)

Independent Appraisal of NSPCD Limited reach Improve data analysis for recognizing early warning signals Communication weak link Focus on urban areas Involve Pvt. Sector Establish int. & ext. QA system 13

Integrated Disease Surveillance Project Integrated Disease Surveillance Project (IDSP) was launched in November 2004. To cover the entire nation in a phased manner Decentralized, State based Surveillance Program. Intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner.

IDSP-Major Components Integrating and decentralization of surveillance activities; Strengthening of public health laboratories; Human Resource Development – Training of State and District Surveillance Officers,, Rapid Response Team, other medical and paramedical staff; Use of Information Technology for collection, collation, compilation, analysis and dissemination of data

Institutional Framework NCDC –Nodal Agency Surveillance Committees at National, State and District levels Surveillance Units at Central, State and District level. Linkages established with all State Head Quarters, District Head Quarters and all Government Medical Colleges under IDSP.

IDSP : Structure Central Surveillance Unit (CSU) State Surveillance Unit (SSU) (35 States/UTs) District Surveillance Unit (DSU) ( 611 Districts) Peripheral Reporting Unit (PRU) Surveillance Unit

Linkages at Central Level Outbreak Investigation & Rapid Response W.H.O. E.M.R. NCD Surveillance MIS & Report RCH NACO NVBDCP RNTCP Programme Monitoring 18

Central Surveillance Unit Project Director National Project Officer NCDC Officers Contractual Staff Consultants Supporting Staff

Route for action on alert IDSP outbreak monitoring cell alerts Block MOH Alert from 1075 Block RRT initiate verification Notify nearest health unit and initiate verification Block PHC begins medical relief measures Block RRT completes investigation and documentation Response for outbreak containment BMOH alerts DSO/SSO Alert from local loop to BMOH telephone

Outbreak Investigating Team - State/District Microbiologist Clinician (Pediatrician/ Physician) * Selected from Programme Officers other than SSO/DSO, based on disease ** Only when vector borne disease is suspected 21

Data Management – Tools & Methods No. of outbreaks in 2008 (n=553) & 2009 (till 45th wk) (n=733) Weekly Data (Monday to Sunday) – no. of cases of epidemic prone diseases Form S (Suspect Cases): Health Workers (Sub Centers) Form P (Probable Cases): Doctors (PHC, CHC, Hospitals) Form L (Lab Confirmed Cases): Laboratories 2. Weekly Outbreak Report (Monday – Sunday) : even NIL report is mandatory Through standard format 22

Data Management – Tools & Methods (2) 3. SOS reporting for disease outbreaks (also for IHR compliance): (i) EWS Format (ii) Supplemental Information thru: IDSP Toll free Number 1075 Media Scanning & Verification Cell Data Transmission through Data Centers in ICT Network IDSP Portal (www.idsp.nic.in) E-mail Data Compilation / analysis and response at all levels; Presently at district/state level 23

Information Flow D.S.U. C.S.U. Weekly Surveillance System S.S.U. Sub-Centers Programme Officers S.S.U. P.H.C.s C.H.C.s D.S.U. Pvt. Practitioners Dist. Hosp. Nursing Homes Private Hospitals Med.Col. Private Labs. P.H.Lab. Corporate Hospitals

Communication Network Satellite Broadband Hybrid Network. 800 sites on a broadband network 400 sites will have dual connectivity with satellite and broadband. Enhanced Speedy Data Transfer, Video Conferencing, Discussions, Training, Communication and in future e-learning for outbreaks and program monitoring

Information & Communication Technology (ICT) Components Network Data Centers Training Centers Video Conferencing System Manpower Software / IDSP Portal (www.idsp.nic.in) 24 X 7 Call Center IDSP portal being used for uploading weekly SPL data, outbreak and FMR

Alerts through IDSP Call Centre Call Centre operational with 1075 toll free number since February 2008 Call received as on 17th January 2010: 1,40,962 No. of Health Alerts : 133 Influenza A H1N1 Calls : 36,918 (from May 2009) Led to detection of 9 outbreaks [Acute Diarrhoeal Disease (4), Chickenpox(3), Dengue (1) and Malaria (1)]

Video Conferencing (VC) Facility VC being used for: Outbreak, Investigation, Verification and Documentation Project Reviewing / Monitoring for different aspects Training of Data Managers & Data Entry Operators A total of 400 VC sessions conducted from Jan- 19th Nov 09

Lab Network for Influenza Surveillance AI Lab network is established . These labs. Are also doing testing for influenza A H1N1. Training of microbiologists and lab technicians completed. All labs are quality checked IGMC Shimla JIPMER Pondicherry SGPGI Lucknow NCDC, Delhi Haffkines Mumbai NIV,Pune CRI Kasauli NIMHANS Bangalore IPM Hyderabad BJ Medical College Ahmedabad Manipal Medical College ICMR Lab : NIV, Pune, AIIMS, Delhi , PGI, Chandigarh, CMC Vellore, RMRC Dibrugarh, NICED Kolkatta ,Patel Chest Delhi, KIPM, Chennai Other labs: Jaipur,Trivandrum,Surat (Total 44 labs. 26 under govt. & 18 pvt.sector)

Model of Referral Lab Network State Referral Lab SSU/DSU/ State Lab Consultant/ State Lab Coordinator District BEED Nashik MaahabubnagarL OgoleL SOUTH GOA MAHESANA Sabarkantha KARNAL PANCHKULA KANGRA MANDI CHITRADURGA TUMKUR BAGALKOT KANNUR WAYANAD PATHANAMTHITTA LUNGLEI KOHIMA SIKAR AJMER Cuddalore ERODE Ramanthapuram THANJAVUR Malda HARDWAR Ghiziabad BELGAUM Lucknow Srinagar Bhopal Chattisgarh Ranchi Dehradun Almora Chandigarh Dadar nagar Haveli Naharlagun Sikkim Curachandpur DelhiA Megalaya Mohali Koraput Kolashib Dimapur Berhampore 30 30

Surveillance & Health regulations Draft of a new “Public Health Emergencies Act” is under process that covers: -Epidemic-prone diseases, health consequences of Disasters & Bio-terrorism -Makes provision for empowering Central/ State Governments to declare condition as PH Emergency & take appropriate measures Draft modified IHR to review the core capacity for public health response

IDSP-Role in Current Response for AI/PI Institutional and operational framework available at Centre/ State/ District levels utilized Substantial human Resource for public health available now as compared to a decade earlier. Trained RRTs at District level Real time Information flow Electronic Data records Enhanced lab capacity (44 labs testing H1N1)

Thank You

Thank you Dedicated to the people of India… who have the right to get the benefits of an efficient surveillance system in the country Thank you