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Integrated Disease Surveillance Project (IDSP): Current Status

MentorProf.(Dr.) E. Venkata RaoCommunity Medicine

PresenterDr. Vivek Varat PattanaikPGCommunity Medicine

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2 Outline

Introduction Management structure of the Integrated Disease Surveillance

Project Reporting units, participants

and their roles Private sector participation in

disease surveillance Case definitions of diseases and

syndromes under surveillance

Working with the laboratory Outbreak investigation, response and control Analysis and interpretation of data Feedback Monitoring, supervision and

quality control Inter-sectoral coordination and social

mobilization Human resources development in the

integrated disease surveillance project

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3 History

1997-98: National Surveillance Program for Communicable Diseases (NSPCD) initiated

March, 2003: Central Surveillance Unit (CSU)

Nov, 2004: Integrated Disease Surveillance Project (IDSP)

2007-08: Making of IDSP as part of National Rural Health Mission (NRHM)

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4 Public health Surveillance Surveillance is defined as the ongoing systematic

collection, collation, analysis and interpretation of data and dissemination of information to those who need to know in order that action be taken.

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5 Public health Surveillance Surveillance is defined as the ongoing systematic

collection, collation, analysis and interpretation of data (disease / health event) and dissemination of information to those who need to know in order that action be taken.

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6Why do we need to do surveillance? Recognize cases or cluster of cases to trigger intervention to prevent transmission or reduce

morbidity and mortality.

Identify high risk groups or geographical areas to target interventions and guide analytic studies.

Develop hypotheses that lead to analytic studies about risk factors for disease causation, propagation or progression.

Assess the public health impact of health events and measure trends.

Demonstrate the need for public health intervention programme and resources during public health planning.

Monitor effectiveness of prevention and control measures and prevent outbreaks.

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7 Objectives of the Integrated Disease Surveillance Project. To establish a decentralized district based system of surveillance for

communicable and non-communicable diseases so that timely and effective public health actions can be initiated in response to health changes in the urban and rural areas.

To integrate existing surveillance activities to avoid duplication and facilitate sharing of information across all disease control programmes and other stake holders so that valid data is available for health decision making in the district, state and national levels

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8 Classification of surveillance in IDSP

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

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Conditions under regular surveillanceType of disease DiseaseVector borne diseases •MalariaWater borne diseases •Diarrhea (Cholera)

•TyphoidRespiratory diseases •TuberculosisVaccine preventable diseases

•Measles

Disease under eradication •PolioOther conditions •Road traffic accidentsInternational commitment •PlagueUnusual syndromes •Meningo-encephalitis

•Respiratory distress•Hemorrhagic fever

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Other conditions under surveillanceType of surveillance

Categories Conditions

Sentinel surveillance

•STDs •HIV/HBV/HCV•Other conditions

•Water quality•Outdoor air quality

Regular surveys •Non communicable disease risk factors

•Anthropometry•Physical activity•Blood pressure•Tobacco, blood pressure•Nutrition•Blindness

Additional state priorities •Up to five diseases

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11 Reporting units for disease surveillance

Public sector (Exhaustive)

Private(Sentinel)

Rural •Community health centres•District hospitals

•Practitioners•Hospitals

Urban •Urban hospitals•ESI•Railways•Medical colleges

•Nursing homes•Hospitals•Medical colleges •Laboratories

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12 Phases of implementation for the Integrated Disease Surveillance Project Phase I (2004-05)

Madhya Pradesh, Andhra, Himachal, Karnataka, Kerala, Maharashtra, Mizoram, Tamil Nadu & Uttaranchal

Phase II (2005-06) Chattisgarh, Goa, Gujarat, Haryana, Orissa, Rajasthan, West

Bengal, Manipur, Meghalaya, Tripura, Chandigarh, Pondicherry, Nagaland, Delhi

Ph III (2006-07) UP, Bihar, J&K, Punjab, Jharkhand, Arunachal, Assam, Sikkim,

A&N Island, D&N Haveli, Daman & Diu, Lakshadweep

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Management structure of the Integrated Disease Surveillance Project

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National surveillance committeeCentral surveillance unit

State surveillance committee State surveillance unit

District surveillance committee District surveillance unit

Organizational structure

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15District surveillance committee

Chairperson

CMORepresentative

Water Board

Superintendent Of Police

IMA Representative

NGO Representative

Medical College Representative

District Surveillance

Officer (Member Secretary)

District Panchayat

Chairperson

District Training Officer(IDSP)

Representative Pollution Board

District Data Manager (IDSP)

Chief District PH Laboratory

District Program Manager Polio,

Malaria, TB, HIV - AIDS

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16 Functions of the district surveillance unit Centralize and analyze data from all reporting units Constitute rapid response teams and their deputation Implement and monitor all project activities Coordinate with laboratories, medical colleges, non

governmental organizations and private sector Send regular feedback to the reporting units Organize training and communication activities Organize district surveillance committee meetings

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17 Functions of state surveillance unit

Collate and analyze data received from districts Coordinate activities of rapid response teams Monitor and review the activities of district surveillance

units Coordinate with state public health laboratories,

medical colleges and other state level institutions Feedback trend analysis to district surveillance units Organize and coordinate training activities Organize meetings of the state surveillance committee

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18 Functions of central surveillance unit Execute the approved annual plan of action Monitor progress of implementation Obtain reports and statements of expenditure Seek reimbursement from the World Bank Report to the national surveillance committee Procure goods and services at central level Analyze data and send feedback to states Coordinate with NICD, ICMR and others Organize non communicable diseases surveys Conduct periodic review meetings with state surveillance officers Organize independent evaluation studies Produce guidelines, manuals and modules

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19 Information flow of the weekly surveillance system

Sub-centres

P.H.C.s

C.H.C.s

Dist. hosp.

Programmeofficers

Pvt. practitionersD.S.U.

P.H. lab.

Med. col.

Other Hospitals: ESI, Municipal Rly., Army etc.

S.S.U.C.S.U.

Nursing homes

Private hospitals

Private labs.

Corporate hospitals

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Reporting units, participants and their roles

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21 Surveillance: A systematic, ongoing process Data collection Transmission Analysis Feedback Action

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22 Reporting unit

Nature Health facility / individual in private/ public sector Located in rural or urban area

Function Collects information of health conditions identified in specified formats Transmits these in pre-specified timely manner to the next higher level

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23 Reporting units for disease surveillancePublic sector

(Exhaustive)Private(Sentinel)

Rural •Community health centres•District hospitals

•Practitioners•Hospitals

Urban •Urban hospitals•ESI•Railways•Medical colleges

•Nursing homes•Hospitals•Medical colleges •Laboratories

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24 Active and passive reporting

Active reporting Health workers

House visits Passive reporting

All other reporting units

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25 Three levels of case definitions for three levels of actors

Level Actor of the surveillance system

•Syndromic(Form “S”) •Health workers

•Presumptive (Form “P”, probable) •Medical officers

•Confirmed •Laboratories

* Except for malaria and tuberculosis

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26 Reportable diseases for multi-purpose health workers and health assistants Diarrhea Jaundice Fever Cough Acute flaccid paralysis Unusual events (Death, hospitalization)

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27 Reportable diseases for medical officers Diarrhea Jaundice Fever

Malaria Typhoid Japanese encephalitis Dengue Measles

Cough Tuberculosis

Acute flaccid paralysis Unusual events (Death, hospitalization)

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28 Zero reporting

Zero reporting is important to confirm that the condition was looked for and not found

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Person responsible for data compilation and transmission

Levels Person responsible

•Primary health centres •Pharmacists

•Community health centres •Computer / pharmacists

•Sentinel private providers •Medical officers

•District hospitals •Computer / pharmacists

•Medical colleges •Statistical officer

•Laboratories •Medical officer / technician

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Time sequence

•Community health centre reports to district

Tuesday

•Primary health centre reports to community health centre

Monday

EventDay of the week

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Private sector participation in disease surveillance

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32 Need for private sector participation in disease surveillance Most patients (>70%) go to private sector Private physicians are the preferred first contact Private sector is more likely to detect early warning signs of outbreak Lack of public sector service provider especially in urban areas

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33 Initiating partnership

MOU (memorandum of understanding) with IMA/IAP/other professional bodies

National/State/District level Training

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34 Criteria for inclusion

Reporting units Hospitals Nursing homes Clinics

Various systems of medicine Geographical distribution Involve professional

associations Indian Medical Association Indian Academy of Pediatrics

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35 Expected numbers of practitioners to include

Rural areas 15-45/100,000 population

Urban areas 15-30/100,000 population

Increase the number in phases More private practitioners in rural areas

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Case definitions of diseases and syndromes under surveillance

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38 Types of case definitions in use

Case definition

Criteria Who uses it

Syndromic Clinical pattern Paramedical personnel and members of community

Presumptive Typical history and clinical examination

Medical officers of primary and community health centres

Confirmed Clinical diagnosis by a medical officer and positive laboratory identification

Medical officer and Laboratory staff

Mo re spe cifi ci ty

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39 Rationale for the use of case definitions Uniformity in case reporting at district, state and national level Use of the same criteria by reporting units to report cases Compatibility with the case definitions used in WHO recommended

surveillance standards• Allow international information exchanges

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40 Levels of case definitions

Suspect case A case that meets the clinical case definition

Probable case A suspect case that is diagnosed by a medical officer

Confirmed case A suspect case that is laboratory confirmed

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41 Levels of response to different triggersTrigger Significance Levels of response

1 Suspected /limited outbreak • Local response by health worker and medical officer

2 Outbreak • Local and district response by district surveillance officer and rapid response team

3 Confirmed outbreak • Local, district and state

4 Wide spread epidemic • State level response

5 Disaster response • Local, district, state and centre

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Conditions under regular surveillanceType of disease DiseaseVector borne diseases •MalariaWater borne diseases •Diarrhea (Cholera)

•TyphoidRespiratory diseases •TuberculosisVaccine preventable diseases •MeaslesDisease under eradication •PolioOther conditions •Road traffic accidentsInternational commitment •PlagueUnusual syndromes •Meningo-encephalitis

•Respiratory distress•Hemorrhagic fever

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Other conditions under surveillanceType of surveillance Categories ConditionsSentinel surveillance •STDs •HIV/HBV/HCV

•Other conditions

•Water quality•Outdoor air quality

Regular surveys •Non communicable disease risk factors

•Anthropometry•Physical activity•Blood pressure

•Tobacco, blood pressure•Nutrition•Blindness

Additional state priorities •Up to five diseases

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44 Working with the laboratory

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45 Role of laboratories in disease surveillance Early diagnosis of diseases under surveillance Epidemiological investigation Rapid laboratory confirmation of diagnosis Implementation of effective control measures

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46 Laboratory network for the Integrated Disease Surveillance Project

Laboratories Description

L1 • Peripheral laboratories and microscopic centres

L2 • District public health laboratory

L3 • Disease based state laboratories

L4 • Regional laboratories and quality control laboratories

L5 • Disease based reference laboratories

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Conditions under regular surveillanceType of disease DiseaseVector borne diseases •MalariaWater borne diseases •Diarrhea (Cholera)

•TyphoidRespiratory diseases •TuberculosisVaccine preventable diseases •MeaslesDisease under eradication •PolioOther conditions •Road traffic injuriesInternational commitment •PlagueUnusual syndromes •Meningo-encephalitis

•Respiratory distress•Hemorrhagic fever

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Other conditions under surveillanceType of surveillance Categories ConditionsSentinel surveillance •STDs •HIV/HBV/HCV

•Other conditions •Water quality•Outdoor air quality

Regular surveys •Non communicable disease risk factors

•Anthropometry•Physical activity•Blood pressure

•Tobacco, blood pressure•Nutrition•Blindness

Additional state priorities •Up to five diseases

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Syndrome Action•Fever •Blood smear for all patients•Acute flaccid paralysis •2 stool samples at interval of 24

hours transported to the medical officer of the primary health centre in reverse cold chain

•Fever with rash, altered sensorium or bleeding

•Refer to the medical officer of the primary health centre for specific laboratory action •Fever more than 14 days

•Cough < or > 3 weeks•Loose watery stools•Acute jaundice •Unusual syndromes

Action to be taken by the multi-purpose worker in the field

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50 Information to be recorded on each specimen/ accompanied with each specimen

Name, age, sex Address in detail Reporting unit referring the sample Syndromic diagnosis Date of onset of illness Nature of sample, date of collection, date of receipt and

condition of sample Investigation requested Whether convalescent specimen or not

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ID no Name and address of patient

Age Sex Prov. Diag.

Lab tests ordered

Lab results

Date sent to L2

Result from L2

Date of result

Sample laboratory register

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52 The L form

Weekly reports from laboratories to the district surveillance officer Prepared on the basis of the laboratory register Filled by nodal person in the laboratory Sent every Saturday of each week

Zero/NIL reporting Electronic link between

District public health laboratory District surveillance unit

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Outbreak investigation, response and control

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54 Definition of an outbreak

Occurrence in a community of cases of an illness clearly in excess of expected numbers

The occurrence of two or more epidemiologically linked cases of a disease of outbreak potential constitutes an outbreak (e.g., Measles, Cholera, Dengue, Japanese encephalitis, or plague)

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55 Sources of information to detect outbreaks Rumour register

To be kept in standardized format in each institution Rumours need to be investigated

Community informants Private and public sector

Media Important source of information, not to neglect

Review of routine data Triggers

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56 Early warning signals for an outbreak

Clustering of cases or deaths Increases in cases or deaths Single case of disease of epidemic potential Acute febrile illness of an unknown etiology Two or more linked cases of meningitis, measles Unusual isolate Shifting in age distribution of cases High vector density Natural disasters

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57 Objectives of an outbreak investigation1. Verify 2. Recognize the magnitude 3. Diagnose the agent4. Identify the source and mode of transmission5. Formulate prevention and control measures

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58 Outbreak preparedness: A summary of preparatory action Formation of rapid response team Training of the rapid response team Regular review of the data Identification of ‘outbreak seasons’ Identification of‘outbreak regions’ Provision of necessary drugs and materials Identification and strengthening appropriate laboratories Designation of vehicles for outbreak investigation Establishment of communication channels in working

conditions (e.g., Telephone)

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59 Basic responses to triggers

There are triggers for each condition under surveillance Various trigger levels may lead to local or broader response Tables in the operation manual propose standardized actions to take

following various triggers Investigations are needed in addition to standardized actions

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60 Levels of response to different triggersTrigger Significance Levels of response

1 Suspected /limited outbreak • Local response by health worker and medical officer

2 Outbreak • Local and district response by district surveillance officer and rapid response team

3 Confirmed outbreak • Local, district and state

4 Wide spread epidemic • State level response

5 Disaster response • Local, district, state and centre

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61 Importance of timely action: The first information report (Form C) Filled by the reporting unit Submitted to the District Surveillance Officer as soon as the suspected

outbreak is verified Sent by the fastest route of information available

Telephone Fax E-mail

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62 The rapid response team

Composition Epidemiologist, clinician and microbiologist Gathered on ad hoc basis when needed

Role Confirm and investigate outbreaks

Responsibility Assist in the investigation and response Primary responsibility rests with local health staff

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63Incidence of acute hepatitis by source of water supply, Bhimtal block, Uttaranchal, India, July 2005

Mehragaon main village

Dov

Water supplySpringReservoirPipeline

Attack rate< 5%5-9%10% +

Mehragaon Hydle colony

ChauriagaonMehragaon

Suspected spring

Place

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64 Specific outbreak control measures

Waterborne outbreaks Access to safe drinking water Sanitary disposal of human waste Frequent hand washing with soap Adopting safe practices in food handling

Vector borne outbreaks Vector control Personal protective measures

Vaccine preventable outbreaks Supplies vaccines, syringes and injection equipment Human resources to administer vaccine Ring immunization when applicable

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65

Analysis and interpretation of data

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66 Selected outcomes of data analysis

Identification of outbreaks / potential outbreaks Identification of appropriate and timely control measures Prediction of changes in disease trends over time Identification of problems in health systems Improvement of the surveillance system through:

Identification of regional differences Identification of differences between the private and the public

sectors Identification of high-risk population groups

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67 Types of data

Syndromic case data Presumptive case data Confirmed case data Sentinel case data Regular surveillance data Urban data Rural data

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68 Basic surveillance data analysis

1. Count, divide and compare Direct comparisons between number of cases are not possible in the

absence of the calculation of the incidence rate2. Descriptive epidemiology

A. TimeB. Place C. Person

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69 Reported varicella and typhoid cases, Darjeeling district, West Bengal, India, 2000-4

Figure 3: Reported varicella and typhoid cases, Darjeeling district, WB, India, 2000-2004

1

10

100

1000

10000

100000

2000 2001 2002 2003 2004

Years

Num

ber o

f cas

es (L

og)

TyphoidVaricella

Incidence by year

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70

MangaloreNallur

Vridha-chalam

Kattumannar Kail Kumaratchi

Parangipattai

Kamma-puram

Panruti

Cuddalore

Annagraman

Kurinjipadi

Bhuvanagiri

Keerapalayam

Reported cases of measles, Cuddalore district, Tamil Nadu, Dec 2004 – Jan 2005

Spot map of absolute number of cases

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71 81%

19%

Immunized Unimmunized

Immunization status of probable measles cases, Nai, Uttaranchal,

India, 2004

Distribution of cases according to a characteristic

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72 Malaria in Kurseong block, Darjeeling District, West Bengal, India, 2000-2004

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Incidence of Pf malaria

Example of monthly and yearly analysis

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73 Review of analysis results by the technical committee Meeting on a fixed day of every week Review of a minimum of:

4 reports weekly 7 reports monthly

Review by disease wise Search for missing values Check the validity Interpret Prepare summary reports and share Take action

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74 Feedback

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75 Difficulties with surveillance system with no feedback Lack of motivation Unreliability Sluggishness Data falsification

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Data collection

Analysis and action

Feedback

The surveillance cycle

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77 Data flow and feedback

Centre

State

District

Primary / Community health centre

Data Feedback

Community

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78 Feedback methods

Newsletters Monthly review meetings Reports Informal feedback Electronic communication

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79

Monitoring, supervision and quality control

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80 Supervision and monitoring

Good supervision helps health staff to perform their best Monitoring is also a vital component of any surveillance programme Monitor all surveillance activities using standard performance indicators District surveillance office monitor indicators of reporting on a regular

basis

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Creative monitoring solutions, Haryana, 2007 District register keeping track

of reports Reporting units that are not

timely are flagged with a highlighter

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82

WEEKS 1 2 3 4 5 6 7 8 9 10 Baripada (DHH) B.Pahad CHC

B.posi Bahalda CHC Barasahi CHC Betnati CHC Bijatala PHC Dukura CHC

G.mahisani PHC Jamda PHC

Jashipur CHC K.tandi UHPHC Kaptipada CHC Karanjia, SDH KC Pur PHC Khunta PHC Kostha CHC Kuliana PHC Manada CHC

Rangamatia PHC Raruan PHC

RG PHC RR Pur, SDH SC Pur PHC Shirsa CHC Sukruli PHC

T.munda CHC Tato PHC Tiring PHC Udala, SDH

Colour-coded monitoring of reporting, Mayurbhanj district, Orissa, India, 2004Legend

Timely, complete

Timely, incomplete

Complete, not timely

Incomplete and late

No reportsThe colour coding stimulates reporting units that are not performing Monitoring

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83 Central agencies responsible for quality control Central surveillance office National Institute of Communicable Diseases (NICD) Indian Council of Medical Research (ICMR)

Quality

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84 Other agencies identified by the Ministry of Health and Family Welfare for external evaluation

World Bank World Health Organization United States Centers for Diseases Control and prevention (CDC) INDIACLEN

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85

Inter-sectoral coordination and social mobilization

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86 Coordination

The process of linking the activities of various departments of an organization

The process by which managers achieve integrated patterns of group and individual effort i.e., Develop unity of action in common purposes

The integration, synchronization or orderly patterning of group efforts by an organization towards the accomplishment of common goals or objectives

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87 Stakeholders

Medical officer of primary health centres Sentinel private practitioners Community representatives District

All members of the district surveillance unit State

All members of the state surveillance unit

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88 Aim of the social mobilization campaign Create awareness among:

Partners Private practitioners Non governmental organizations Community

Establish an institutional mechanism to involve community and their leaders Rotating membership in:

District surveillance committee Block surveillance committee

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89 Strategizing communication

Adapt message and format to the audiences Consider all media

Electronic media Press Hoardings Handbills Posters Inter-personal communication through health providers

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90 Being close from the community

People volunteer in areas where health workers enjoy a good relationship with their communities

Individual initiatives taken by enthusiastic health staff make a difference

Key contacts Village elders’ Ladies Pradhan (Village head) Panchayat members Chowkidar (Village guard)

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91 Engaging medical colleges

Responsibility of the state surveillance unit Memoranda of understanding

Selection of a coordinating medical college by the Director of Medical Education

Facilitation by the health secretary Possibility for medical colleges to work in urban surveillance Contacts at the central level will facilitate these synergies

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92 Institutional Integrated Disease Surveillance Project sub-committee within medical colleges Principal / superintendent

Report to Integrated Disease Surveillance Project Community medicine Medicine Pediatrics Chest and tuberculosis Microbiology Cardiology

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93 Additional potential roles of medical colleges Reference laboratories Quality assurance and evaluation Training Outbreak investigations

In collaboration with the district surveillance officer / medical officer Non communicable disease risk factor surveillance

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94

Human resources development in the integrated disease surveillance project

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95 Principles for human resources development in the Integrated Disease Surveillance Project

No additional staff to be employed Existing personnel will be provided training Training will be provided locally Public private partnership Quality assurance process in the training of the trainers process

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96 Categories of trainees

I. State and district surveillance teamsII. Medical officersIII. Clinical medical officersIV. Sub-block staffV. State and district level laboratory staffVI. Laboratory staff at sub district levelVII. Data entry operatorsVIII. Statisticians at district and state level

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97 Induction training courses

1. State and district teams (The trainers)2. Medical officers

PHC / CHC / Urban Health services / Medical colleges3. Medical officers

• Private sector 4. Peripheral workers 5. Microbiologists and technicians - State and district 6. Laboratory technicians at sub district level 7. Data entry operators - State/ district/ sub district8. Data managers - District and State

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98 Location and duration of the trainingTarget audience Site Duration

1. Trainers Region / state 6 days

2. Medical officers District headquarters 3 days

3. Other officers District headquarters 1 day

4. Health workers Community health centre 2 days

5. Microbiologists Region / state 6 days

6. Lab assistants District headquarters 3 days

7. Data operators District headquarters 2 days

8. Data managers Region / state 3 days

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99

Thank You