Transcript Disease Surveillance in India

Framework for implementation of
revised IHR 2005
in India
Dr Sampath K Krishnan
Coordinator CDS & IHR Contact Point
World Health
Organization
Country Office -
Presentation
1.
2.
3.
Health Legislation & Governance
Disease surveillance
• NSPCD
• IDSP
Plan of action for implementation of IHR in
India
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Constitutional allocation of Government powers
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Federal structure - Health is a state subject in the
main
Central (Union) list, State list & Concurrent list
Central list has more of public health legislations
whereas state list also has legislations for health
emergencies
Concurrent list also contains important areas
concerning public health which can be taken up
by state or centre.
Pandemic diseases could be declared as Public
health disasters and centre could take controlWorld Health
e.g. SARS, Avian Flu, Pandemic Flu
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Constitutional protections
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Constitution of India guarantees right to life
(Article 21). Right to health as a pre-requisite
recognized by the Supreme Court.
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Under Directive Principles of the State, health
care is the responsibility of the State (Nation)
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Public health can override individual rights
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E.g. in Avian influenza-social isolation and limited
quarantine were introduced in affected areas
• Poultry farmers supported culling operations.
• Protests could occur even if legislations are in place
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Constitutional procedural requirements
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Enactments/ amendments would be required for
effective implementation of IHR
But presently, could be implemented under
existing health/other legislations (even though
some are quite old)
Other legislations also may be used when
necessary
• E.g. Criminal Procedure Code (CrPC) in MP and Police
Act in Maharashtra imposed during avian influenza
outbreak (under maintenance of public law and order)
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Federal system
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Health is a state subject in the main hence states
usually enact their own health legislations
States usually have their own surveillance systems in
place. Were earlier reporting on a monthly basis to
Central Bureau of Health Intelligence for about 30
diseases of PH importance
NSPCD programme ensured that the 101 districts in
these states reported outbreaks directly to Centre
(NICD)
States sometimes report late to Centre due to various
reasons including awaiting lab confirmation of
diagnosis
States obtain significant funding from centre for
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All sub-centres
PHC/CHC- Temporary staff, drugs, lab equipment
Anganwadis –ICDS (creche)
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Role of centre in control of important diseases of
public health importance
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Detailing of central teams for assisting
investigation and response
Capacity building and laboratory support
Project mode-IDSP, NACP, RNTCP, NPSP. These
then become National Health Programmes (may
have some component of external funding)
Emergencies (SARS, Avian Influenza)
States can also directly obtain external funding
for health but centre has to give clearance
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National Health Programmes
Significant surveillance component
Disease specific and vertical in approach
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Malaria
Filariasis
Kala azar
Leprosy
Tuberculosis
Poliomyelitis
HIV/AIDS
Vaccine preventable
diseases
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RCH
Cancer control
Blindness
Mental Health
Iodine deficiency
Water supply
Total Sanitation
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Statutory and administrative law issues
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Statutory reform
• Changes to existing legislations at national and
state levels is an ongoing process
• Disease surveillance is not a legal requirement at
central level, but some states have it
• Examples of existing legislations governing key IHR
related issues
 Public Health Act 1925
• Public Health emergencies Act being processed
(Epidemic Diseases Act 1897 being repealed)
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Prevention of extension of Infectious disease
from one state to another (Concurrent list Entry 29)
Port quarantine (Union List entry 28, Constitution of India)
National Disaster Act 2005
Right to Information Act 2005
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Public Health Emergencies Act (under process)
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To provide for the control and management of
public health emergencies (including PHEIC)
Scope of the Act:
• Dangerous epidemic disease (potential to
spread rapidly)
• Epidemic prone diseases (29 diseases + PHEIC
when notified by WHO)
• Bio-terrorism (34 agents + others)
• Disasters (19 disasters + others)
• Centre would have powers to direct states
• Declare area of PHE for 3 months duration at a
time
Need for a draft (model) PHE Act for countries to
adapt
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Vertical policy coordination and coherence
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Current strategy
• National Rural Health Mission, NHPs
• All India Services – Bureaucrats (IAS, IPS),
Central Government Health Scheme, etc
• Regional Offices of Health & Family Welfare
(cover all states/UTs) monitor implementation
of central health schemes
• Communications is entirely under Centre
Dispute resolution
• Central Council for Health & Family Welfare
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Fiscal and budgetary issues
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Adequate resources to fulfill the basic obligations
of IHR implementation
Funds would be required for capacity building at
• Centre
• State & districts
• Public Health Laboratories
• Border crossings
• Port and airport health authorities
• Hospitals for admitting large numbers of
patients under isolation
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IHR and non-governmental actors
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Municipal Corporations especially large Metros
Defence
Airlines
Railways
Shipping
Travel & Tourism
Exporters
Hospitals
Media
NGOs
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Media
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Freedom of press a major factor in frequent
reporting of outbreaks
Often report ‘mysterious illness/unknown disease’
which does alert international health networks. All
disease outbreaks would fall in this category until
lab confirmed.
24 hr news channels (repeat the news, does create
apprehension and also significant economic impact)
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Health authorities use it to convey the status report
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Play a positive role in IEC
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Public health surveillance and response
infrastructure
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National Surveillance Programme for
Communicable Diseases
Integrated Disease Surveillance Project (WB
supported) for 5 years
Budgetary support planned under XI Five-year
Plan
Laboratory strengthening under IDSP as well as
additional funds for Pandemic Flu preparedness
Training of Health staff on-going
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Disease surveillance
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Disease surveillance in India has always been
practiced by the states (health being a state subject)
Many gaps, differed in degree and quality of
surveillance, different priorities in diseases, lack of
uniformity
Rapid Response Teams (RRTs) functioning but weak
Information was made available at National level only
at monthly intervals
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National Surveillance Programme for
Communicable Diseases (NSPCD)
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NSPCD was therefore launched by the Centre in
1997-98 in five pilot districts of the country
(centrally sponsored scheme) and over the years
extended to cover 101 Districts in all 35 states and
UTs in the country.
In this programme the states were the
implementing agencies and NICD Delhi was the
Nodal agency for coordinating the activities.
This programme was based on outbreak reporting
(as and when outbreaks occur) with weekly
reporting of epidemic prone diseases directly from
Districts (including nil reporting) to the Centre.World Health
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Main components
To establish Early Warning System (EWS) so as to
institute appropriate and timely response for
prevention & control of outbreaks
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Every state/UT and all the 101 districts had a trained
multi-disciplinary Rapid Response Team
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Rapid communications (through e-mails & fax)
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Strengthening of state and district laboratories for rapid
confirmation of diagnosis
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Capacity development of health staff in the districts
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IEC (information, education and communication)
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Districts covered under NSPCD
1997-98 (25 districts)
1998-99 (20 districts)
2000-01(35 districts)
2001- 02 (20+1 districts*)
* The district of Shimla taken as
a special case during 2002-03
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Diseases/pathogens covered
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Epidemic prone communicable diseasesacute diarrhoeal diseases including cholera,
viral hepatitis, dengue, Japanese
encephalitis, meningitis, measles, viral
haemorrhagic fevers, leptospirosis, others
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Pathogens with bioterrorism potential
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Drug resistant pathogens
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Expected outcome
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Early detection of outbreaks
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Early institution of containment measures
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Reduction in morbidity & mortality
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Minimize economic loss
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Profile of outbreaks investigated by NSPCD
districts
100
105
85
80
60
57
40
14
8
3
20
57
0
6 86
0
53
10 7 7
1
69
13 1
5 12
21 5
0 02
00 2
Chickenpox
Food
Poisoning
Measles
JE
Malaria
0
ADD
(GE,Diarrhoea,
Dysentry)
No. of outbreaks
120
Type of outbreak
2001
2002
2003
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NSPCD
NSPCD has significantly improved the capacity of these
districts and states to detect investigate and respond to
outbreaks, yet
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It was not case based reporting and did not give a
complete picture of disease burden in the country
especially in respect of epidemic prone diseases
GoI not convinced to expand this programme to all 600
districts in the country
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Integrated Disease Surveillance Project (IDSP)
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Integrated Disease Surveillance Project (IDSP) was
conceptualized and the Govt of India approached the
World Bank for the necessary funding (US $ 68 M
over five yrs)
Objectives:
• To establish a decentralized system of disease
surveillance for timely and effective public health
action
• To improve the efficiency of disease surveillance
for use in health planning, management and
evaluating control strategies
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Target diseases in IDSP
Sentinel Surveillance
Regular Weekly Surveillance
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Malaria
ADD (Cholera)
Typhoid
Tuberculosis
Measles
Polio
Plague
Unusual Syndromes
State Specific Diseases
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HIV, HBV, HCV
Accidents
Water Quality
Outdoor Air Quality
Community-based Surveys
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NCD Risk factors
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Phasing of Integrated Disease Surveillance
Project
Phase-I (04-05)
Phase II (05-06)
Phase III (06-07)
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Organizational structure
National Surveillance Committee
Central Surveillance Unit
State Surveillance Committee
State Surveillance Unit
District Surveillance Committee
District Surveillance Unit
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Information flow
Weekly Surveillance System
Sub-Centres
Programme
Officers
S.S.U.
P.H.C.s
C.H.C.s
Dist.Hosp.
D.S.U.
P.H.Lab.
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Pvt. Practitioners
Nursing Homes
Private Hospitals
Med.Col.
World Health
Organization
C.S.U.
Private Labs.
Other Hospitals:
ESI, Municipal
Rly., Army etc.
Corporate
Hospitals
Linkages at Central level
W.H.O.
Outbreak Investigation
& Rapid Response
MIS & Report
NCD Surveillance
CSU
NICD
ICMR
NVBDCP
E.M.R.
RNTCP
National
Programs
CBHI
RCH
Programme Monitoring
NACO
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Network of Reference Laboratories for
Surveillance of in India
Kasauli
Delhi
New Delhi
Lucknow
Dibrugarh
Ahmedabad
Kolkata
Mumbai
Pune
Proposed BSL-3
under ICMR
Bangalore
Chennai
L5 labs
Pondicherry
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Activities planned under
National Rural Health Mission
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Accredited Social Health Activist (ASHA) to be
the community based informant for Disease
Surveillance
Computerization up to PHC level, establishing
connectivity with District Surveillance Unit
Setting up Distance Learning Communication
Channel using EduSat
Strengthen Laboratory Services at PHC level
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Use of EDUSAT in Distance Learning
& Communication for IDSP/NRHM
EDUSAT
REMOTE CLASSROOMS
TEACHING END
ROT
TV/Monitor
Teacher
/Board
Touch Screen
TEACHERS/STUDENTS
DVD Player
PC/ Web-Camera
PTZ Camera
SIT
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RETURN LINK
(Live Voice/ Voice Mail/Text Message)
WLL
Strengths of IDSP
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Functional integration of surveillance components
of vertical programmes
Reporting of suspect, probable and confirmed
cases –syndromic reporting from periphery
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Strong IT component for data analysis
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Trigger levels for gradated response
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Action component in the reporting formats
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Streamlined flow of funds to the districts
World Health
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Jammu & Kashmir

WHO collaborative network
Himachal
Pradesh
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Punjab
Uttaranchal
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
Haryana Delhi

Uttar Pradesh
Rajasthan
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
 
Assam
Bihar

Madhya Pradesh
 
Gujarat
sh
rade
lP
acha
Arun
Sikkim
isgarh
Chatt



Nagaland
Mizoram

Manipur

Tripura
West Bengal
Jharkhand
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Mizoram
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
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Orissa
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Daman & Diu
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Dadra & Nagar
Haveli
 Filariasis
 Malaria
 HIV/AIDS
Kar
na
taka
 Kala Azar
Andhra
Pradesh
 Routine Immunization



la

 Plague Surveillance
land



Tamil
Nadu
Is
obar

 Hep B
& Nic
Lakshadweep
Kera
nce

man
Anda
ation
Polio
Leprosy
ance
Goa
Tuberculosis
Disease Surveillance
Maharashtra
 
 
Legend
Plan of Action
World Health
Organization
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National Workshop of all Stakeholders for effective
implementation of Revised IHR (2005), 20-21 April 2006
To prepare a plan of action and list out the activities for
establishing/ strengthening of core capacities for surveillance
and response (as per annex – 1A of IHR document) at
National/State and District level
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To prepare a plan of action and list out the activities for
establishing/ strengthening of core capacities (as per annex
– 1B of IHR document) at Designated airports, Ports, and
Ground crossings
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To suggest a mechanism for:
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Collaboration between different stakeholders at National / State/
District level and at designated Airports/ Ports/ Ground crossings
Addressing the administrative and legal issues related to
implementation of IHR 2005
World Health
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Planning for
Strengthening of core capacities for surveillance and response
S.
NO.
ACTIVITIES
TIME LINE
RESPONSIBLE
AGENCIES
1
Strong linkages between IHR & IDSP
June 2006
IDSP, NFP
2
Strong component of IHR in all IDSP trg
December 2006
IDSP, NFP
3
All RRTs should be aware of the
information needed to be reported
December 2006
IDSP, NFP
4
Increase awareness about IHR among
administrators and politicians at
national / state/ district levels
December 2006
IDSP, NRHM, IH
5
Electronic transmission of data
including GIS from phase I districts
December 2006
IDSP
6
Electronic transmission of data from
districts under phase II of IDSP
June 2007
IDSP
7
Electronic transmission of data from
districts under phase III of IDSP
December 2007
IDSP
8
Designation of surveillance officers of
state & district surveillance units as
state/ district IHR focal points
December 2006
IDSP
9
Mechanism for rumor verification to be
strengthened at district/ state/ national
level
June 2007
IDSP
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Planning for
Strengthening of core capacities for surveillance and response (cont’d 2)
10
Evaluation of laboratory capacities at state
and district levels and their strengthening
December
2006
IDSP & State
Governments
11
At least one laboratory (L4 level of IDSP) in
each state (more in bigger states) to be
identified / strengthened
December
2007
State Governments
& IDSP
12
At least one BSL4 laboratory under the
Ministry of Health, GOI – which should be
linked to IDSP and NFP
December
2008
MOHFW
13
Preparation for state / district health
contingency plans and their periodical
updating
December
2007
State Governments
14
Evaluation of isolation facilities and hospital
infection practices in all districts/ states
December
2007
State Governments
15
Involvement of private sectors for disease
surveillance by sensitization, persuasion,
training, legislation and also through
professional organizations like IMA
December
2007
State Governments
& IDSP
16
GOI may expedite approval of Public Health
Emergency Act 2005
December
2006
MOHFW
17
All surveillance officers to have the list of big
and small international airports, ports and
ground crossings and invite them in
surveillance meetings
December
2006
IDSP & State
Governments
World Health
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Planning for
Strengthening of core capacities for surveillance and response (cont’d 3)
18
APHOs/ PHOs to be included in the state
surveillance committees
December
2006
IDSP, Min of
Shipping, Civil
Aviation, DGHS
19
Assessment of disease surveillance and response
capacity as mentioned under the IHRidentification of responsible agency, preparation
of assessment instrument & methodology and
provision of resources
June 2007
IDSP, MOHFW
20
Establishment of a mechanism for periodic
independent evaluation of IDSP
June 2007
IDSP
21
National RRT must be involved for investigation
of events if more than one state is involved
December
2006
IDSP & State
Governments
22
State RRT must be involved for investigation of
events if more than one district is involved
December
2006
IDSP, MOHFW
23
A copy of the investigation report should be
given to the district collector or Municipal
commissioner
December
2006
IDSP, MOHFW,
State govts
MHA
24
Findings of investigations of central RRT should
be urgently conveyed to states and the findings
of state RRT should be urgently conveyed to
district
December
2006
MOHFW, State
Governments
25
All major laboratories in the country testing
clinical samples should start reporting to IDSP
December
2006
IDSP
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Planning for
Strengthening of core capacities for surveillance and response (cont’d 4)
26
Identification of high-risk areas near the
international borders and establish/activate the
programme for cross border control of diseases
June 2007
IDSP, State
Govts., MOHFW,
MEA
27
Strengthening of capacity including trained
manpower for disease surveillance and response
at central level (e.g., NICD, Emergency Medical
Response division of Dte. GHS), to provide support
to the states during PHEIC
December
2007
MOHFW
28
The proposal for conversion of NICD to National
Centres for Disease Control (NCDC) may be put on
fast track
December
2007
NICD, MOHFW
29
Strengthening of capacity for disease surveillance
and response at state and district level
December
2007
State Govts
30
Involvement of major institutions and National
Health Programmes like ICMR, NVBDCP in
assessment and investigation of public health
events
December
2006
MOHFW
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Planning for
Strengthening of core capacities for surveillance and response (cont’d 5)
31
Existing disease control guidelines to be updated
and widely circulated, issue new guidelines for
emerging diseases, and their periodic updating
June 2007
NICD & IDSP
32
National IHR focal point (NICD) should have the
linkages with international reference labs and
should have the authority to directly send the
biological material to them
December
2006
NICD, MOHFW
33
Satellite linkages of IDSP and national IHR focal
point with all state and district HQs
June 2007
IDSP
34
Establishment of mechanism for collaboration and
coordination between different Ministries/
Departments
June 2007
MOHFW
35
Preparation of a National Public Health Emergency
Response Plan
December
2007
IHR focal point,
MOHFW, MHA
World Health
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Planning for
Strengthening of core capacities of ports and ground crossings
S.NO.
ACTIVITIES
TIME LINE
RESPONSIBLE
AGENCIES
1
Identification of airports, ports and
ground crossings for implementation of
IHR
June 2006
MOHFW (ADG,IH)
M/O Civil Aviation
M/O Shipping
MHA
2
Assessment of present capacities at the
designated airports, ports and ground
crossings
June 2007
M/O Civil Aviation
M/O Shipping
MHA
MOHFW (ADG,IH)
3
Taking a policy decision about who will
provide the health services at the
designated airports, ports and ground
crossings (in context of privatization)
December
2006
M/O Civil Aviation
M/O Shipping
MHA
4
Filling up of vacant posts for
strengthening of medical services at the
designated airports, ports and ground
crossings
December
2007
M/O Civil Aviation
M/O Shipping
MHA
MOHFW
5
Establishing a referral system for medical
services at the designated airports, ports
and ground crossings
December
2007
M/O Civil Aviation
M/O Shipping
MHA
MOHFW
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Planning for
Strengthening of core capacities of ports and ground crossings (cont’d 2)
6
Creation of new public health units at designated
ports, airports and ground crossings (at present
there are 6 APHOs, 8 PHOs and one ground level
Health organization)
December
2007
MOHFW
7
Improvement of physical infrastructure of
quarantine centers at designated airports, ports
and ground crossings
December
2007
MOHFW
8
Training of technical staff of designated airports,
ports and ground crossings on IHR (2005)
December
2007
MOHFW
NFP
IDSP
9
Provision of ambulance at all designated airports,
ports and ground crossings
December
2007
M/O Civil
Aviation M/O
Shipping
MHA
MOHFW
10
District IDSP laboratories be designated for each
airport/ port/ ground crossing health
organizations
June 2007
MOHFW, IDSP
State Govts.
M/O Civil
Aviation M/O
Shipping
MHA
World Health
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Planning for
Strengthening of core capacities of ports and ground crossings (cont’d 3)
11.
Provision of entomologist at all the health units for
vector surveillance and control activities
December
2007
MOHFW
12.
Linkages with IDSP:
Link with website
Networking with IDSP laboratories
June 2007
MOHFW,
IDSP
State Govts.
13.
Preparation of Public Health Emergency Contingency
plan including:
Preparation of panel of doctors/ paramedical staff
for deputation during Public Health Emergency
Identifying referral laboratories and medical
facilities
Coordination amongst:
December
2007
MOHFW
(ADG,IH)
Designated hospitals,
Department of Animal Husbandry,
Designated laboratories,
Immigration contact point,
Airport/ ship management agencies,
Customs contact point
World Health
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Planning for
Collaborative, administrative and legal issues
S. NO
ACTIVITIES
TIME LINE
RESPONSIBLE
AGENCIES
1
Examination of IHR (2005) document for
administrative and legal issues
July 2006
MOHFW
2
Examination of health certificates/
documents and charges mentioned in IHR
(2005) and to revise national certificates/
documents and charges, if necessary, and
communicate to the WHO
June 2007
MOHFW
3
Examination of National Aircraft/Port Health
Act and Rules and to revise/amend them, if
necessary, for effective implementation of
IHR (2005)
June 2007
MOHFW
4
Prepare/Update Health rules for designated
Ground Crossings
June 2007
MOHFW
MHA
World Health
Organization
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Planning for
Collaborative, administrative and legal issues (cont’d 2)
5
Presently MHA provides emergency support services and
coordination between different sectors during
emergencies. The same mechanism should be used for
the purpose of Public Health Emergencies of
International Concern under the IHR.
December
2006
MOHFW,
MHA
6
Coordination committees:
Mechanism for coordination and collaboration between
different sectors at various levels (National, State and
District) already exists under IDSP. These committees
should be suitably expanded for the purpose of IHR.
Nodal members to be identified from the following
ministries/ organizations:
December
2007
MOHFW,
MHA
MOHFW
Designated hospitals, laboratories and various pest/
vector control agencies
State Health Directorates, District Health Authorities
Local municipality, cantonment board, any other relevant
agency
Ministries of Civil Aviation, Shipping, Surface transport,
Agriculture (veterinary dept.), Home Affairs, Tourism,
Railways
Customs, Immigration, AAI
Association of shipping agents
World Health
Organization
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Obstacles to implementation
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Inter-sectoral coordination (Av Flu)
Border crossings (large border and large number
of migrants)
Frequent large outbreaks (daily 3-5 important
outbreaks-presently Chikungunya, Japanese
encephalitis, Leptospirosis)
World Health
Organization
Country Office -
Thank You