NCD Risk Factor Surveillance in India: Leveraging Research to National Action

Dr Prashant Mathur

Assistant Director GeneralDIVISION OF NONCOMMUNICABLE DISEASES

INDIAN COUNCIL OF MEDICAL RESEARCHNEW DELHI, INDIA

Email: mathurp@icmr.org.in

5th International Conference Behavior Risk Factor Surveillance, 24-26th October 2007, Rome, Italy

‘Grave’ picture for 2005, India

Diabetes2%

Injuries11%

Chronic resp diseases

7%

Cancer8%

CVD28%Comm.

disease36%

Total projected deaths 10.4 million

Chronic disease death 5.5 million

60 million deaths over the next decade

Communicable disease deaths reduction by 15 %

Deaths from diabetes increase by 35%

Reddy KS, Cherian V, Shah B, Ramadoss A. Responding to the threat of chronic diseases in India. LANCET Oct 5, 2005

National Programs for NCD

National Program for the Prevention and Control of BlindnessNational Cancer Control ProgramNational District Mental Health ProgramNational Policy for the Elderly

National Program for CVD, Diabetes & Stroke

Rehabilitation program- Accident &TraumaOral Health Program

Vision for NCD Surveillance

R

E

S

E

A

R

C

H

A

D

V

O

C

A

C

Y

P

O

L

I

C

Y

BackgroundLack of standardized community based data from various regions of country

2001 - ICMR identified as Nodal agency by WHO & Govt. of India to undertake NCD RFS

Identification of key partners in NCD surveillance to expand it at a National level

The WHO STEPwise approach to Surveillanceaddresses a step wise collection of data depending on capacity &resources permits a reasonable amount of flexibility provides opportunity for international comparison of data

Challenge Tackled at Policy Level

Interpretation of STEPS data asrepresentative of the prevalence of various parameters in the community

need to differentiate between ‘survey’ and ‘surveillance’

Development of Sentinel Health Monitoring Centers In India, 2003-05

(ICMR-WHO Collaboration)

Goal: To develop a sustainable system for NCD Surveillance in IndiaAim: To set up Regional Sentinel Health Monitoring Centers

6 sites; 15-64 years (decadal age groups) Urban/Rural/Slum; M/F 44800 respondents (STEP 3 in 20% sub-sample)

Alcohol consumptionTobacco consumptionInadequate intake of fruits & vegetablesPhysical inactivity

ObesityBody Mass Index (BMI)Waist circumference

Elevated blood pressure

Biochemical Parameters (Fasting)

LipidsTotal CholesterolHDL cholesterolTriglycerides

Plasma glucose

Risk Factors Studied

Nagpur

Trivandrum

Chennai

Dibrugarh

BallabgarhDelhi

ICMR’s NCD Risk Factor Surveillance Centers in IndiaCoordinating Unit : Division of NCD, ICMR

21.49

35.91

21.96

32.25

20.2

33.61

0

5

10

15

20

25

30

35

40

Urban Rural Slum0

1000

2000

3000

Urban Rural Slum

Smokers Daily

88.3% 86.7%84.5%

60.8

16.6

49.2

12.3

56.9

14.7

0

10

20

30

40

50

60

70

Urban Rural Slums

25- 29.9

7.7

23.2

31.5 30.426.3

2.5

911.4 10.2 8.6

4.1

17.419.3 18.4

15.6

0

5

10

15

20

25

30

35

15-24 25-34 35-44 45-54 55-64

BMI Categories (Kg/m2)

Prop

ortio

ns (%

)

Urban Rural Slum

% daily smokers amongst current smokersAge at Initiation of Smoking

ICMR-WHO NCD RF Study: Glimpses of Results

Servings of Fruit Consumption/day BMI: Overweight

1

2-5

Urban Rural Slum

Quality Assurance

Common protocol Field staff training by the centre PIAdapted Questionnaire was translated into local language and back translatedCentral supply of instrumentsSite visits and close monitoring through

Telephone, fax, e mails, frequent meetings

Quality Assurance

Common data entry template in Epi-info 6.0 developed and distributed10% double data entryCentre specific data analysis and reportingCombined data analysis in SPSS (12.0) by the central coordinating unit

Leveraging Research to National Action Plan

Identification of experienced partners in 5 regions of India

Data collected through a uniform study protocol in a time frame

Team of investigators at local & regional levels

Locally relevant translated study instrument & field manual

Strong coordination, monitoring, supervision, data management

Commitment of participating institutions

Interaction with planners, policy makers & International agencies

Developed a template for National NCD RF Surveillance

The Concept of IDSP(Integrated Disease Surveillance Program)

World Bank funded project through Ministry of HealthThereafter to be run by the Govt. of India (National Rural Health Mission)

DecentralizedIntegratedAction orientedBrings together communicable and NCD under one surveillance activity.

--

1

1

1

1

1

1

11

1

3

2

2

2

2

2

2

23

3

3

33

2

3

Number indicates Phasing of the Project

Planned in 29 States/UTs in 3 phases (2007-10)To be repeated every 3 yrs at State levelMajor NCD Risk factors identified

Behavioral: tobacco (smoke, smokeless), alcohol, fruits & vegetables, physical activityPhysical: BMI, waist circumference, BPBiochemical: fasting blood glucose, cholesterol

State level estimates of NCD risk factors

IDSP NCD RF Surveillance

Nagpur

Ballabgarh

Dibrugarh

Chennai

Trivandrum

NCD Risk Factor Surveys under IDSP: ICMRs Resource Centers

8 States being covered under Phase I of IDSP

Andhra PradeshKarnatakaKeralaTamilNaduMaharashtraMadhya PradeshUttaranchalMizoram

CSU – IDSPMin of HealthCSU – IDSP

Min of Health

World Bank & Associates

World Bank & Associates

State IDSPState IDSP

ICMRRegional Research Centers

State Survey Agencies

National Nodal Agency

Stakeholders

COMMUNITY

Data collectionIdentification & referral

Technical issues

District Surveillance Committee/ District Health Authority

Co-ordination

Survey Team

Management of referralsProvide logistic support

National Nodal Agency

Survey methodology, questionnaire, training, quality, monitoring, analysis, reporting, dissemination

Medical Colleges

Dissemination, Management of patients, Planning a Response

Administrative Financial Reporting

Regional Research Centres

Training, QC, Technical support

State Survey Agency

National TechnicalAdvisory Committee

Central Surveillance Unit IDSPMin of Health

ICMRQuality, StandardizationAdministrative, Financial Reporting

National Monitoring Committee

Study AreasUrban and Rural

Study PopulationMales and females aged between 15-64 years in the selected urban and rural areas

Study designCross sectional survey (to be repeated every 3-5 yrs)

Sampling StrategyMulti-stage systematic cluster sampling technique

3 sections Check list of household members and eligibility

Household information on SE parameters

Individual respondents questionnaire

Common protocolStandardized trainingStandardized survey methodsMonitoring and coordinating set upsAdvisory Group and ResourcesSite visitsCommon data management mechanismsCritical appraisal

PUBLIC HEALTH INTERVENTIONS

Policy Interventions Educational Interventions

Enabling Environment Health Beliefs and Behaviours

(Financial, Social, Physical) (Community; Individual)

Desired Change

The Future of NCD Surveillance in India

Integrating laboratory parameters in surveillanceState level NCD Policy Community based intervention programsDisease surveillance Integral part of the soon to be launched National Program on Cardiovascular Diseases, Diabetes and StrokeLinkages with Health databases

NCD cell at the centreState NCD cells established in all the States100 Medical Colleges and 200 Districts with capacity for NCD prevention & management 20 Resource Centres establishedIEC strategy implementedHealth sector personnel trained in NCDSurveillance of risk factors initiated and sustained -linkages with IDSP.

National Programme for Prevention and Control of Diabetes, Cardiovascular

Diseases and Stroke (NPCDCS)

NCD Surveillance Team at ICMRDr NK Ganguly

Director General, ICMR

Dr Bela ShahChief, Division of NCD

Dr DK ShuklaDeputy Director General

Dr Prashant MathurAssistant Director General & Program Officer, NCD Surveillance

Dr Geetha MenonResearch Officer

InvestigatorsK Anand – BallabgarhV Mohan – ChennaiJ Mahanta – DibrugarhNG Desai – DelhiPP Joshi – NagpurKR Thankappan - Trivandrum

Advisory CommitteeLM NathKS ReddyRM PandeyMG KarmarkarPadam SinghSK Pradhan

Hope on the Horizon for NCDs!!

THANK YOU !