Transcript IDSP Module 14

Surveillance of the risk factors
for non-communicable diseases (NCDs)
IDSP training module for state and
district surveillance officers
Module 14
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
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
Communicable versus
non-communicable diseases
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Communicable diseases
Sudden onset
Single cause
Short natural history
Short treatment schedule
Cure is achieved
Single discipline
Short follow up
Back to normalcy
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Non-communicable diseases
Gradual onset
Multiple causes
Long natural history
Prolonged treatment
Care predominates
Multidisciplinary
Prolonged follow up
Quality of life after
treatment
Projected proportional increase in
population > 65 years age, 2000-2030
Italy
Japan
UK
USA
China
India
Chile
Mexico
0%
50%
100%
150%
200%
Proportion (%)
Social Determinants of Health Inequalities, Marmot M, Lancet 2005
250%
Projected population pyramid of India
Proportion (%)
Estimated and projected proportion of
deaths due to non-communicable
diseases, India, 1990-2010
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Injuries
Communicable diseases
Non communicable diseases
1990
2000
Year
2010
Estimated and projected specific mortality
rate per 100,000, by sex, India
1985
All causes
Infectious
Neoplasms
Circulatory
Pregnancy
Perinatal
Injury
Other
M
1158
478
43
145
0
168
85
239
2000
F
1165
476
51
126
22
132
65
293
M
879
215
88
253
0
60
82
280
2015
F
790
239
74
204
12
48
28
285
M
846
152
108
295
0
40
84
167
F
745
175
91
239
10
30
29
171
Epidemiological transition: The concept of evolution from a
communicable diseases burden of disease profile
to a predominance of non communicable disease
Source : World Bank Health Sectorial Priorities Review
Burden of major non-communicable
diseases, India, 2004
Stroke
Ischemic heart diseases
No. in
millions
45
40
35
30
25
20
15
10
5
0
No. in
millions
7
39.40
6.36
6
5.28
5
4
3
16.00
0
0.55
No. of YLL
0.63
1
4.95
No. of cases No.of DALY
1.64
2
No. of
cases
No. of
deaths
Diabetes
No. in
millions
66.58
70
60
50
40
30
20
10
2.26
1.15
0.11
No.of DALY
No. of YLL
No. of deaths
0
No. of cases
No.of DALY No. of YLL
No. of
deaths
Non communicable disease
programmes in India
A.
B.
C.
D.
E.
F.
G.
H.
National cancer control programme
National mental health programme
National blindness control programme
Cardiovascular diseases, stroke and diabetes
programme
Trauma and accident programme
Oral health programme
Rehabilitation programme
Geriatric care programme
Existing reporting systems for non
communicable diseases in India
• Sentinel surveillance systems
 National Cancer Registry Programme
• Periodic surveys/studies
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Census of India
Sample registration systems
National sample surveys
National family health survey
National nutrition monitoring programme
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)
Implementation of non communicable
diseases programmes in countries of the
WHO South East Asia region
Countries
Tobacco control
Cardio
vascular
diseases
Bangladesh
Cancer
Diabetes
1982
1978
Integrated
control
Bhutan
DPR Korea
India
2000
2000
Indonesia
2000
1975
1989
1995
Maldives
Myanmar
2001
1982
Nepal
Sri Lanka
1999
Thailand
1988
1982
1996
1999
1998
1988
1993
2000
2000
1988
1988
1993
Source:Non-Communicable Diseases in South-East Asia Region, A Profile, WHO, 2002
Prioritizing surveillance for
non communicable diseases
? Mortality?
? Morbidity?
? Disability?
 Risk factors
 The risk factors of today
are the diseases of
tomorrow
Life course approach for the prevention
of non communicable diseases
Foetal
life
•SES
•Maternal
nutritional
status &
obesity,
•Fetal
growth
Infancy and Adolescence
childhood
•SES
•Nutrition
•Diseases
•Linear
growth
•Obesity
•Obesity
•Lack of
activity
•Diet
•Alcohol,
•Smoking
•SE potential
Adult Life
•Established adult risk factors
(behavioural/biological)
Range of
individual
risk
Accumulated
Accumulated
risk
risk
Age
The causal chain explains the risk factor
approach for surveillance of non
communicable diseases
Behavioral
risk factors
• Tobacco
• Alcohol
• Physical
inactivity
• Nutrition
Physiological
risk factors
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Body mass index
Blood pressure
Blood glucose
Cholesterol
Disease
outcomes
• Heart disease
• Stroke
• Diabetes
• Cancer
• Respiratory diseases
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
Step 3
(Biological)
Step 2
(Physical)
Complexity
The WHO STEPwise approach to
surveillance of non-communicable
disease risk factors
At each step
Core
Step 1
(Verbal)
Expanded
Optional
Sequential approach, step by step
Heterogeneity of non-communicable
risk factors in India
Kerala
Different
dietary
patterns
Delhi
Different
body
composition
Jammu &
Kashmir
Different
habits
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
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
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:
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Prevalence of risk factors and unhealthy life style
Time trends
Geographical distribution
Distribution among various populations
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
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
Target population for survey
• Population of 15 years to 64 years.
• 10-year age groups
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15-24
25-34
35-44
45-54
55-64
• Sampling technique
 National Family Health Survey
• Cluster sample survey
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
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
Survey instrument
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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
Information collection
• Questionnaire
• Measurement
 Height
 Weight
 Blood pressure
• Biochemical results
 Fasting blood glucose
 Serum cholesterol
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
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
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
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
Ensuring validity
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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
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
Quality assurance
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Common protocol
Standardized training
Standardized survey methods
Monitoring and coordinating set ups
Advisory group and resources
Site visits
Common data management mechanisms
Critical appraisal
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
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
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
Follow up action
• Coordinated approach for community level
interventions
• Partnerships
 Medical colleges, state health departments,
primary health care services and nongovernmental organisations
• Dissemination of health education material
on causes, prevention and incentives to
enhance public awareness
High risk and population approaches to
prevention
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
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
Intervention strategies
• Population based strategy
 Prevent non-communicable diseases in the whole
population
• High-risk strategy
 Target people with identified risk factors
Public health interventions
Policy interventions
Educational interventions
Enabling environment
(Financial, Social, Physical)
Health beliefs and behaviours
(Community; Individual)
Desired change
Challenges and opportunities
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Challenges
Huge population
Many programmes
Rural population
Emerging epidemics
Unemployed youth
Burden of non
communicable diseases
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Opportunity
Good sample size
Different strategies
Complex exposures
Interventions
Trained workforce
Feasible intervention
Points to remember (1/3)
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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
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
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