Integrated Disease Surveillance Project (IDSP)

Integrated Disease Surveillance Project (IDSP) was launched by Hon’ble Union Minister of Health & Family Welfare in November 2004 for a period upto March 2010. The project was restructured and extended up to March 2012. The project continues in the 12th Plan with domestic budget as Integrated Disease Surveillance Programme under NHM for all States with Budgetary allocation of 640 Cr.

A Central Surveillance Unit (CSU) at Delhi, State Surveillance Units (SSU) at all State/UT head quarters and District Surveillance Units (DSU) at all Districts in the country have been established.

Objectives:
To strengthen/maintain decentralized laboratory based IT enabled disease surveillance system for epidemic prone diseases to monitor disease trends and to detect and respond to outbreaks in early rising phase through trained Rapid Response Team (RRTs)


Programme Components:
Integration and decentralization of surveillance activities through establishment of surveillance units at Centre, State and District level.
Human Resource Development – Training of State Surveillance Officers, District Surveillance Officers, Rapid Response Team and other Medical and Paramedical staff on principles of disease surveillance.
Use of Information Communication Technology for collection, collation, compilation, analysis and dissemination of data.
Strengthening of public health laboratories.

1. Integrated Disease Surveillance Project (IDSP): Current Status 1 7/29/2016 Mentor Prof.(Dr.) E. Venkata Rao Community Medicine Presenter Dr. Vivek Varat Pattanaik PG Community Medicine

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 2 7/29/2016

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) 7/29/2016 3

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. 4 7/29/2016

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. 5 7/29/2016

6. Why 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. 6 7/29/2016

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 7 7/29/2016

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 8 7/29/2016

9. Conditions under regular surveillance Type of disease Disease Vector borne diseases Malaria Water borne diseases Diarrhea (Cholera) Typhoid Respiratory diseases Tuberculosis Vaccine preventable diseases Measles Disease under eradication Polio Other conditions Road traffic accidents International commitment Plague Unusual syndromes Meningo -encephalitis Respiratory distress Hemorrhagic fever 7/29/2016 9

10. Other conditions under surveillance Type 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 7/29/2016 10

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 7/29/2016 11

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 7/29/2016 12

13. Management structure of the Integrated Disease Surveillance Project 13 7/29/2016

14. National surveillance committee Central surveillance unit State surveillance committee State surveillance unit District surveillance committee District surveillance unit Organizational structure 7/29/2016 14

15. District surveillance committee 15 7/29/2016

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 7/29/2016 16

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 7/29/2016 17

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 7/29/2016 18

19. Information flow of the weekly surveillance system Sub-centres P.H.C.s C.H.C.s Dist. hosp. Programme officers Pvt. practitioners D.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 7/29/2016 19

20. Reporting units, participants and their roles 20 7/29/2016

21. Surveillance: A systematic, ongoing process Data collection Transmission Analysis Feedback Action 7/29/2016 21

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 7/29/2016 22

23. 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 7/29/2016 23

24. Active and passive reporting Active reporting Health workers House visits Passive reporting All other reporting units 7/29/2016 24

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 7/29/2016 25

26. Reportable diseases for multi-purpose health workers and health assistants Diarrhea Jaundice Fever Cough Acute flaccid paralysis Unusual events (Death, hospitalization) 7/29/2016 26

27. Reportable diseases for medical officers Diarrhea Jaundice Fever Malaria Typhoid Japanese encephalitis Dengue Measles Cough Tuberculosis Acute flaccid paralysis Unusual events (Death, hospitalization) 7/29/2016 27

28. Zero reporting Zero reporting is important to confirm that the condition was looked for and not found 7/29/2016 28

29. 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 7/29/2016 29

30. Time sequence Community health centre reports to district Tuesday Primary health centre reports to community health centre Monday Event Day of the week 7/29/2016 30

31. Private sector participation in disease surveillance 31 7/29/2016

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 7/29/2016 32

33. Initiating partnership MOU (memorandum of understanding) with IMA/IAP/other professional bodies National/State/District level Training 7/29/2016 33

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 7/29/2016 34

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 7/29/2016 35

36. 7/29/2016 36

37. Case definitions of diseases and syndromes under surveillance 37 7/29/2016

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 More specificity 7/29/2016 38

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 7/29/2016 39

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 7/29/2016 40

41. Levels of response to different triggers Trigger 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 7/29/2016 41

42. Conditions under regular surveillance Type of disease Disease Vector borne diseases Malaria Water borne diseases Diarrhea (Cholera) Typhoid Respiratory diseases Tuberculosis Vaccine preventable diseases Measles Disease under eradication Polio Other conditions Road traffic accidents International commitment Plague Unusual syndromes Meningo -encephalitis Respiratory distress Hemorrhagic fever 7/29/2016 42

43. Other conditions under surveillance Type 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 7/29/2016 43

44. Working with the laboratory 44 7/29/2016

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 7/29/2016 45

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 7/29/2016 46

47. Conditions under regular surveillance Type of disease Disease Vector borne diseases Malaria Water borne diseases Diarrhea (Cholera) Typhoid Respiratory diseases Tuberculosis Vaccine preventable diseases Measles Disease under eradication Polio Other conditions Road traffic injuries International commitment Plague Unusual syndromes Meningo -encephalitis Respiratory distress Hemorrhagic fever 7/29/2016 47

48. Other conditions under surveillance Type 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 7/29/2016 48

49. 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 7/29/2016 49

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 7/29/2016 50

51. 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 7/29/2016 51

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 7/29/2016 52

53. Outbreak investigation, response and control 53 7/29/2016

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) 7/29/2016 54

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 7/29/2016 55

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 7/29/2016 56

57. Objectives of an outbreak investigation Verify Recognize the magnitude Diagnose the agent Identify the source and mode of transmission Formulate prevention and control measures 7/29/2016 57

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) 7/29/2016 58

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 7/29/2016 59

60. Levels of response to different triggers Trigger 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 7/29/2016 60

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 7/29/2016 61

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 7/29/2016 62

63. Incidence of acute hepatitis by source of water supply, Bhimtal block, Uttaranchal, India, July 2005 Mehragaon main village Dov Water supply Spring Reservoir Pipeline Attack rate < 5% 5-9% 10% + Mehragaon Hydle colony Chauriagaon Mehragaon Suspected spring Place 7/29/2016 63

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 7/29/2016 64

65. Analysis and interpretation of data 65 7/29/2016

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 7/29/2016 66

67. Types of data Syndromic case data Presumptive case data Confirmed case data Sentinel case data Regular surveillance data Urban data Rural data 7/29/2016 67

68. Basic surveillance data analysis Count, divide and compare Direct comparisons between number of cases are not possible in the absence of the calculation of the incidence rate Descriptive epidemiology Time Place Person 7/29/2016 68

69. Reported varicella and typhoid cases, Darjeeling district, West Bengal, India, 2000-4 Incidence by year 7/29/2016 69

70. Mangalore Nallur 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 7/29/2016 70

71. 81% 19% Immunized Unimmunized Immunization status of probable measles cases, Nai, Uttaranchal, India, 2004 Distribution of cases according to a characteristic 7/29/2016 71

72. Malaria in Kurseong block, Darjeeling District, West Bengal, India, 2000-2004 5 10 15 20 25 30 35 40 45 January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December 2000 2001 2002 2003 2004 Months Incidence of malaria per 10,000 Incidence of malaria Incidence of Pf malaria Example of monthly and yearly analysis 7/29/2016 72

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 7/29/2016 73

74. Feedback 74 7/29/2016

75. Difficulties with surveillance system with no feedback Lack of motivation Unreliability Sluggishness Data falsification 7/29/2016 75

76. Data collection Analysis and action Feedback The surveillance cycle 7/29/2016 76

77. Data flow and feedback Centre State District Primary / Community health centre Data Feedback Community 7/29/2016 77

78. Feedback methods Newsletters Monthly review meetings Reports Informal feedback Electronic communication 7/29/2016 78

79. Monitoring, supervision and quality control 79 7/29/2016

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 7/29/2016 80

81. Creative monitoring solutions, Haryana, 2007 District register keeping track of reports Reporting units that are not timely are flagged with a highlighter 7/29/2016 81

82. W EEKS 1 2 3 4 5 6 7 8 9 10 Baripa d a (DHH) B.Pahad CHC B.po s i Bahal d a CHC Baras a hi CHC Betnat i CHC Bijat a la PHC Dukura CHC G. m ahisa n i PHC Ja m da PHC Ja s hipu r CHC K.tand i UHPHC Kapti p ada CHC Karan j ia, SDH KC Pur PHC Khunta PHC Kosth a CHC Kulia n a PHC M anada CHC Ranga m at i a PHC Raruan PHC RG PHC RR Pur , SDH SC Pur PHC Shirs a CHC Sukru l i PHC T . m unda CHC T ato PHC T irin g PHC Udala, SDH Colour-coded monitoring of reporting, Mayurbhanj district, Orissa, India, 2004 Legend Timely, complete Timely, incomplete Complete, not timely Incomplete and late No reports The colour coding stimulates reporting units that are not performing Monitoring 7/29/2016 82

83. Central agencies responsible for quality control Central surveillance office National Institute of Communicable Diseases (NICD) Indian Council of Medical Research (ICMR) Quality 7/29/2016 83

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 7/29/2016 84

85. Inter-sectoral coordination and social mobilization 85 7/29/2016

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 7/29/2016 86

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 7/29/2016 87

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 7/29/2016 88

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 7/29/2016 89

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) 7/29/2016 90

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 7/29/2016 91

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 7/29/2016 92

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 7/29/2016 93

94. Human resources development in the integrated disease surveillance project 94 7/29/2016

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 7/29/2016 95

96. Categories of trainees State and district surveillance teams Medical officers Clinical medical officers Sub-block staff State and district level laboratory staff Laboratory staff at sub district level Data entry operators Statisticians at district and state level 7/29/2016 96

97. Induction training courses State and district teams (The trainers) Medical officers PHC / CHC / Urban Health services / Medical colleges Medical officers Private sector Peripheral workers Microbiologists and technicians - State and district Laboratory technicians at sub district level Data entry operators - State/ district/ sub district Data managers - District and State 7/29/2016 97

98. Location and duration of the training 7/29/2016 98 Target 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

99. Thank You 7/29/2016 99