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1. Integrated Disease Surveillance
Project (IDSP): Current Status
1
12/25/2016
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
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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.
5
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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.
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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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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
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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
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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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14. National surveillance committee
Central surveillance unit
State surveillance committee
State surveillance unit
District surveillance committee
District surveillance unit
Organizational structure
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15. District surveillance committee
15
Chairperson
CMO
Representative
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.
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 12/25/2016
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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 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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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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28. Zero reporting
Zero reporting is important to confirm that the condition was looked for and not
found
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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
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30. Time sequence
•Community health centre
reports to district
Tuesday
•Primary health centre
reports to community
health centre
Monday
Event
Day of the week
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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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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
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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 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
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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
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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
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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 12/25/2016
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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
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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
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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
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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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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
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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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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 investigation
1. Verify
2. Recognize the magnitude
3. Diagnose the agent
4. Identify the source and
mode of transmission
5. 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 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
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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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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
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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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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 rate
2. Descriptive epidemiology
A. Time
B. 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
Number
of
cases
(Log)
Typhoid
Varicella
Incidence by year
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72. Malaria in Kurseong block, Darjeeling
District, West Bengal, India, 2000-2004
0
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
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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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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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81. 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.po
si
Bahal
daCHC
BarasahiCHC
Betnat
i CHC
Bijatala PHC
Dukura CHC
G.mahisani PHC
JamdaPHC
Jashipu
r CHC
K.tand
iUHPHC
KaptipadaCHC
Karan
jia,SDH
KC PurPHC
Khunta PHC
Kosth
aCHC
KulianaPHC
ManadaCHC
Ranga
matiaPHC
Raruan PHC
RG PHC
RR Pur
, SDH
SC Pur PHC
ShirsaCHC
Sukru
li PHC
T.mundaCHC
TatoPHC
Tiring 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
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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 12/25/2016
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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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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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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 teams
II. Medical officers
III. Clinical medical officers
IV. Sub-block staff
V. State and district level laboratory staff
VI. Laboratory staff at sub district level
VII. Data entry operators
VIII. 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 colleges
1. Medical officers
• Private sector
2. Peripheral workers
3. Microbiologists and technicians - State and district
4. Laboratory technicians at sub district level
5. Data entry operators - State/ district/ sub district
6. Data managers - District and State
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98. Location and duration of the training
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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
