This document discusses surveillance of risk factors for non-communicable diseases (NCDs) in India. It describes the need for NCD risk factor surveillance given the increasing burden of NCDs. Surveillance of risk factors like tobacco use, alcohol consumption, obesity, diet, physical activity and blood glucose/cholesterol levels is recommended through periodic sample surveys. The role of district surveillance officers includes organizing such surveys involving collection of demographic, behavioral and biological data on NCD risk factors from the community. Ensuring valid and reliable surveillance methods is important to generate accurate data on trends and patterns of NCD risk factors.

1. Surveillance of the risk factors
for non-communicable diseases (NCDs)
IDSP training module for state and
district surveillance officers
Module 14

2. Learning objectives (1/2)
• Describe the importance and the need for
surveillance of risk factors for non
communicable diseases
• Enumerate the differences between
surveillance for communicable diseases and
risk factors for non communicable diseases
• List non communicable disease risk factors
under surveillance

3. Learning objectives (1/2)
• List steps involved in organization and
conduct of surveillance of risk factors for
non communicable diseases
• Describe the role of the district surveillance
officer in surveillance of risk factors for non
communicable diseases

4. Communicable versus
non-communicable diseases
Communicable diseases
• Sudden onset
• Single cause
• Short natural history
• Short treatment schedule
• Cure is achieved
• Single discipline
• Short follow up
• Back to normalcy
Non-communicable diseases
• Gradual onset
• Multiple causes
• Long natural history
• Prolonged treatment
• Care predominates
• Multidisciplinary
• Prolonged follow up
• Quality of life after
treatment

5. Social Determinants of Health Inequalities, Marmot M, Lancet 2005
Projected proportional increase in
population > 65 years age, 2000-2030
0% 50% 100% 150% 200% 250%
Mexico
Chile
India
China
USA
UK
Japan
Italy
Proportion (%)

6. Projected population pyramid of India

7. Estimated and projected proportion of
deaths due to non-communicable
diseases, India, 1990-2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1990 2000 2010
Year
Proportion
(%)
Injuries
Communicable diseases
Non communicable diseases

8. Source : World Bank Health Sectorial Priorities Review
Estimated and projected specific mortality
rate per 100,000, by sex, India
1985 2000 2015
M F M F M F
All causes 1158 1165 879 790 846 745
Infectious 478 476 215 239 152 175
Neoplasms 43 51 88 74 108 91
Circulatory 145 126 253 204 295 239
Pregnancy 0 22 0 12 0 10
Perinatal 168 132 60 48 40 30
Injury 85 65 82 28 84 29
Other 239 293 280 285 167 171
Epidemiological transition: The concept of evolution from a
communicable diseases burden of disease profile
to a predominance of non communicable disease

9. Ischemic heart diseases Stroke
Diabetes
Burden of major non-communicable
diseases, India, 2004

10. Non communicable disease
programmes in India
A. National cancer control programme
B. National mental health programme
C. National blindness control programme
D. Cardiovascular diseases, stroke and diabetes
programme
E. Trauma and accident programme
F. Oral health programme
G. Rehabilitation programme
H. Geriatric care programme

11. Existing reporting systems for non
communicable diseases in India
• Sentinel surveillance systems
 National Cancer Registry Programme
• Periodic surveys/studies
 Census of India
 Sample registration systems
 National sample surveys
 National family health survey
 National nutrition monitoring programme

12. Sources of data collection for non
communicable diseases in India
• Mortality data
 Medical certificates for death
 Cause of death surveys
 Hospital records
• Morbidity data
 Registry (Cancer)
 Special surveys
 Hospital reports
• Risk factors
 Special surveys
• Registries
 Cancer (Shift from hospital to community based)
 RF/RHD (Jai Vigyan Mission)
 Thalasemia (Jai Vigyan Mission)

13. Countries Tobacco control Cardio
vascular
diseases
Cancer Diabetes Integrated
control
Bangladesh 1982 1978
Bhutan
DPR Korea 2000 2000
India 2000 1975
Indonesia 1989 1995
Maldives 2001
Myanmar 1982 1982 1996 1993
Nepal 1999 1998
Sri Lanka 1999 2000 2000
Thailand 1988 1988 1988 1988 1993
Source:Non-Communicable Diseases in South-East Asia Region, A Profile, WHO, 2002
Implementation of non communicable
diseases programmes in countries of the
WHO South East Asia region

14. Prioritizing surveillance for
non communicable diseases
? Mortality?
? Morbidity?
? Disability?
 Risk factors
 The risk factors of today
are the diseases of
tomorrow

15. Age
Foetal
life
Adult Life
Adolescence
Infancy and
childhood
•SES
•Nutrition
•Diseases
•Linear
growth
•Obesity
•Obesity
•Lack of
activity
•Diet
•Alcohol,
•Smoking
•SE potential
•Established adult risk factors
(behavioural/biological)
•SES
•Maternal
nutritional
status &
obesity,
•Fetal
growth
Accumulated
risk
Range of
individual
risk
Accumulated
risk
Life course approach for the prevention
of non communicable diseases

16. Disease
outcomes
• Heart disease
• Stroke
• Diabetes
• Cancer
• Respiratory diseases
Physiological
risk factors
• Body mass index
• Blood pressure
• Blood glucose
• Cholesterol
Behavioral
risk factors
• Tobacco
• Alcohol
• Physical
inactivity
• Nutrition
The causal chain explains the risk factor
approach for surveillance of non
communicable diseases

17. Rationale of the risk factor approach for
non communicable diseases
• Non communicable diseases are slowly evolving
 Early recognition difficult
• A number of risk factors influence one or more non
communicable diseases
• Risk factors have the greatest impact on non
communicable diseases mortality and morbidity
• Effective modification of risk factors is possible
through primary prevention
• Projections may be used to estimate burden
• Simple surveillance systems can be used
• Measurements standardized and validated and
obtainable within ethical limits

18. Step 3
(Biological)
Complexity
Step 2
(Physical)
Step 1
(Verbal)
Core
Expanded
Optional
At each step
The WHO STEPwise approach to
surveillance of non-communicable
disease risk factors
Sequential approach, step by step

19. Kerala
Delhi
Jammu &
Kashmir
Nagaland
Bihar
High literacy rate, developed
Metropolitan city, highly
urbanized, heterogeneous
population
Nested population
Terrain, relatively
underdeveloped
Nested population
Underdeveloped, Tribes and
Terrain
Illiterate, Poor population
Rural, Agricultural, Tribals
Different
dietary
patterns
Different
body
composition
Different
habits
Heterogeneity of non-communicable
risk factors in India

20. Risk factors under surveillance
• Tobacco use
• Alcohol consumption
• Raised blood pressure
 Systolic and diastolic
• Obesity
 Height, weight, body mass index, waist circumference
• Diet
 Low fruit, high fat, added salt to served food
• Physical inactivity
• Diabetes mellitus
 Fasting plasma glucose
• High serum cholesterol

21. How surveillance for non-communicable
diseases differs
• Surveillance methods:
 Estimating the prevalence of risk factors
 Periodic sample surveys in each state every five
years
• Data generated:
 Prevalence of risk factors and unhealthy life style
 Time trends
 Geographical distribution
 Distribution among various populations

22. Type and frequency of surveys
• Periodic sample surveys conducted in states
once in five years
• 20% of districts surveyed each year
• Whole population covered in 5 years
• Survey conducted every year in randomly
selected districts in a five-year cycle

23. Organization of the surveys
• Practical implementation
 Institution with sufficient epidemiological
capacity
 Best bidders
• Coordination and supervision
 State directorate of public health
 State surveillance unit
 District surveillance unit

24. Target population for survey
• Population of 15 years to 64 years.
• 10-year age groups
 15-24
 25-34
 35-44
 45-54
 55-64
• Sampling technique
 National Family Health Survey
• Cluster sample survey

25. Sample size
• 2500 persons across the 15-64 years age
range
 250 participants in each 10-years age group
• Two strata
 2500 individuals in urban area
 2500 individuals from rural area

26. Proposed survey design
• Primary sampling unit
 Village in case of rural area
 Ward (Census Enumeration Block) in case of urban area
• Stratification of primary sampling units based on
selected variables
• House-listing in primary sampling units
• Within each selected household, all male and
female members aged between 15-64 years are
surveyed

27. Survey instrument
• A pre-tested simple questionnaire
• Developed on the basis of the WHO (STEPS)
• Modified for the Indian context
• Already in use for sentinel surveillance for
cardiovascular risk factors in 10 selected
industrial populations all over India

28. Information collection
• Questionnaire
• Measurement
 Height
 Weight
 Blood pressure
• Biochemical results
 Fasting blood glucose
 Serum cholesterol

29. Step 1: Individual questionnaire (1/2)
• Baseline demography
 Identification, age, sex, education, occupation
• Alcohol consumption
 Current drinkers, frequency, quantity
• Tobacco (Smoking and smokeless)
 Age at initiation, usage, cessation

30. Step 1: Individual questionnaire (2/2)
• Diet, fruits and vegetables
 In a typical week, frequency and quantity
• Physical activity
 At work, transportation and leisure
• History of diagnosis and treatment
 Hypertension and diabetes

31. Data collection instrument and analysis
• Computer friendly data collection
instrument
• Easy data entry
• Automated data analysis through programme
• Generation of information on trends and
patterns of non communicable disease risk
factors

32. Findings and their uses
• Information generated on non communicable
disease risk factors:
 Trends
 Prevalence in various areas
 Distribution in the populations
• Uses:
 Document the need for prevention and control
programmes in the community
 Influence policy makers
 Guide financial allocation

33. Ensuring validity
• Maximize response fraction
• Use valid and reliable instruments
• Calibrate instruments
• Train staff
• Ensure participation of individuals selected
 Reduces the probability that those who do attend are
unrepresentative of the sample
• Engage district surveillance officer and other health
personnel
• Use existing local public health infrastructure

34. Role of the district public health
laboratories
• Conduct tests:
 Blood sugar
 Cholesterol
• Co-ordinate collection, transport and receipt
of the samples from the periphery
• Plan capacity to carry out analyses quickly
• Ensure quality control of biochemical assays
 Key factor to ensure useful results

35. Quality assurance
• Common protocol
• Standardized training
• Standardized survey methods
• Monitoring and coordinating set ups
• Advisory group and resources
• Site visits
• Common data management mechanisms
• Critical appraisal

36. Ethical considerations
• Questionnaires dealing with lifestyle issues and
simple non-invasive measurements
 Verbal consent
• Blood pressure
 Need to clarify whether persons with elevated readings
would be followed up and treatment provided
 Written consent needed
• Collection of blood
 Requires prior ethical clearance
 Built-in plans for treatment of those with raised levels
• Built-in consent form in the questionnaire

37. Promise to care
• Referral, diagnostic and treatment support
to persons identified with non communicable
disease risk factor will be built into the
system
• Patients identified with hypertension,
diabetes will be referred to the next level
for treatment

38. Timing of the survey
• Physiological and cultural considerations
• Overnight fasting needed
 Start early in the morning (6:00 am)
 Finish early in the afternoon (1:00 pm)
• Rest of the day
 Coding forms
 Dealing with the laboratory specimens and other
documentation
 Preparations for the next day

39. Follow up action
• Coordinated approach for community level
interventions
• Partnerships
 Medical colleges, state health departments,
primary health care services and non-
governmental organisations
• Dissemination of health education material
on causes, prevention and incentives to
enhance public awareness

40. Truncate high risk end of
exposure distribution (e.g.,
organize an obesity clinic).
Clinical approach to disease
prevention
Reduce a small amount of risk in a
large number of people (e.g., reduce
fat a little in fast-food outlets).
Lifestyle change plus environmental
approach
High risk and population approaches to
prevention
More burden from a large proportion of the population exposed to moderate
risk factors than from a small segment exposed to a high risk factor

41. Intervention strategies
• Population based strategy
 Prevent non-communicable diseases in the whole
population
• High-risk strategy
 Target people with identified risk factors

42. Public health interventions
Policy interventions Educational interventions
Health beliefs and behaviours
(Community; Individual)
Desired change
Enabling environment
(Financial, Social, Physical)

43. Challenges
• Huge population
• Many programmes
• Rural population
• Emerging epidemics
• Unemployed youth
• Burden of non
communicable diseases
Opportunity
• Good sample size
• Different strategies
• Complex exposures
• Interventions
• Trained workforce
• Feasible intervention
Challenges and opportunities

44. Points to remember (1/3)
• The burden of diseases due to non communicable
diseases in India became almost equal to that due
to communicable diseases in 1990
• The burden of non communicable diseases is
increasing while it is declining in developed
countries because of surveillance and interventions
• The life style related modifiable risk factors for
non communicable diseases have been identified
and the magnitude of their impact is documented

45. Points to remember (2/3)
• The major non communicable diseases share
common, preventable life style risk factors
• There is sound evidence that non
communicable diseases can be reduced
through a package of simple, effective and
feasible life style changes
• The treatment of non communicable
diseases is expensive and therefore the key
to control is in its primary prevention

46. Points to remember (3/3)
• Non communicable diseases surveillance is therefore
considered an important component of the
integrated disease surveillance project
• Non communicable diseases surveillance will be
done by periodic surveys of selected risk factors and
will be independent of regular surveillance for other
conditions
• The Non communicable disease risk factors to be
measured in include: tobacco use, alcohol
consumption, high blood pressure, obesity, diet,
physical inactivity, fasting plasma glucose and serum
cholesterol