The Integrated Disease Surveillance Program (IDSP ) of India story by Dr. Pramod Jacob

Considering the Nipah virus containment story recently, I thought it would be appropriate to write about the IDSP program in India, as it had a major role in this containment.

The Integrated Disease Surveillance Project (IDSP) was launched in November 2004 with the assistance of the World Bank, to identify and respond to disease outbreaks and epidemics at an early stage, preferably before an event becomes an epidemic. 


There were 4 Components:      
a. Decentralisation and integration of surveillance activities through establishment of surveillance units at district, state and central levels 
b. Human Resource Development with training of State Surveillance Officers, District Surveillance Officers, Rapid Response Teams and other relevant staff 
c. Use of information technology for collection, compilation, analysis and dissemination of data and 
d. Enhancement of Public Health Laboratories. 

The following Objectives were to be met 
1. Cover limited number of diseases of public health importance which needed public health response 
2. Implement multiple methods of surveillance 
3. Be a proactive program with timely response at all levels i.e. Be an Early Warning and Response (EWAR) program 
4. Use Information Technology to facilitate information gathering, collation, analysis and dissemination      
5. Decentralise and have states take ownership and 
6. Centre be responsible for coordination, quality control, policy formulation, finance management and technical assistance.

It was realised that though the healthcare infrastructure in India had grown over the years, disease surveillance had not got the required attention in the past, resulting in late detection of disease outbreaks with related morbidity and mortality. One of the main reasons for this shortcoming was the time-consuming and labour-intensive manual methods of data collection, transmission, analysis and feedback for response with paper. 

Hence a countrywide Information and Communication Technology (ICT) network was established under IDSP with the help of National Informatics Centre (NIC) and Indian Space Research Organisation (ISRO). This IDSP network connects the District Surveillance Offices to the State Surveillance Offices which then connects to the Central Surveillance Office at the National Centre for Disease Control (NCDC). 

The network is also presently being deployed to CHC and even PHC levels in some states. The network is used for data entry, compilation, analysis and feedback from data coming in from the sub centre level and above. It has video conferencing ability to help in meetings and training sessions. Furthermore, there is an IDSP portal ( www.idsp.nic.in ), which is a one-stop portal for data entry, reports, outbreak reporting, data analysis and training modules related to disease surveillance.

The IDSP program has three methods of surveillance 
1.  Indicator Based Surveillance 
2.  Event Based Surveillance and 
3.  Media Surveillance. 

Briefly describing each of these: -


Indicator Based Surveillance

There are three levels where these indicators are collected: - 

S form – this form is filled by the sub-center health worker and collects collated details on conditions such as Fever, Cough, Loose watery stools, Jaundice and Acute Flaccid Paralysis (AFP). These forms are submitted to the supervising primary care centre once a week and fed into the IDSP system via the District Surveillance Unit (DSU).

P form – this form is filled by the primary care providers and collects collated data on about 20 different conditions including the above plus additional conditions such as Pertussis, Diphtheria, Leptospirosis etc. This is also submitted on a weekly basis and uploaded into the IDSP system weekly via the DSU.

L form – this is the form collected from public health (and private) Labs for positive test results for specific diseases such as Dengue, Japanese encephalitis , Cholera etc. The difference in these forms are that for each positive result, further details such as the patient name, age, address, test done and lab confirmation diagnosis is also recorded. These forms also go into the IDSP network via the DSU on a weekly basis.

For more details about information on each of these forms please visit the following link 
http://idsp.nic.in/index1.php?lang=1&level=1&sublinkid=5850&lid=3781

From the DSU the information gets instantaneously transmitted to the State Surveillance Unit (SSU) and then the Central Surveillance Unit (CSU) via the IDSP network. This network has been effectively working since 2010. The result is that the CSU based in the National Centre for Disease Control (NCDC), has been publishing nationwide outbreaks of these specific diseases on a week by week basis about a month later (On June 20th could see the outbreaks that occurred in the week of May 14th to May 20th) – here is the link 
http://www.idsp.nic.in/index4.php?lang=1&level=0&linkid=406&lid=3689

Event Based Surveillance

Since public health only covers about 30 percent of the population – it was realized that there had to be a mechanism in place to identify and respond to events such as suspected outbreaks like epidemics or events that could endanger the public. 

An incident maybe reported through the rumour registry or through review of indicator-based surveillance data or through the media.  Whenever there is such an incident reported and verified, there is an Early Warning Signal (EWS) protocol carried out, to which a Rapid Response Team (RRT) of a district investigates and takes the appropriate action. 

The Rapid Response Team in a district is a multi-faceted team looking into various aspects of a potential outbreak. The suggested members would be an epidemiologist, a clinician and a microbiologist/virologist. The RRT is not a permanent team but is formed when the need arises from existing resources in the concerned district under the aegis of the DSU. After an initial investigation by the concerned Medical Officer with filing of an Early Warning Signal/Outbreak report, the RRT verifies the outbreak through Medical and Lab investigations, with the epidemiologist studying the epidemiological and environmental aspects of the outbreak including source of the problem and routes of transmission. 

Once the answers for the causal agent, source of infection, transmission pattern and people at risk are found, the RRT comes up with the specific recommendations and action plan to curtail the outbreak to be implemented by the concerned public health staff which can include state and central (NCDC) levels if needed. This may include steps such as identifying infection isolation points, enforcing infection control protocols, organizing logistics such as special protective gear, burial protocol and sites, tracking and quarantine of contacts, ensuring disease awareness and precautions to be taken by the public. It was this mechanism that played a major role in control and containment of the recent Nipah virus outbreak in the country.   

Media Surveillance

NCDC and some states have a Media Scanning and Verification Cell that monitors Global, National and Regional electronic and print media for reports on suspected outbreaks or unusual health events. It disseminates such reports to the concerned districts digitally for verification and follow up. The major part of the screening is manual with a process in place for filtering genuine from fake news. There are plans afoot to bring in automation into the screening process.

In summary it is a combination of all the above three methods that bring about the Early Warning mechanism for outbreaks and potential epidemics in India. While there is much room for improvement- the IDSP program has proven the effectiveness of a nationwide IT network and in-fact can potentially be upgraded to be the Healthcare IT highway for the country.  


"Dedicated to the IDSP program and public health staff of India – who do so much with so little. Often criticized, seldom appreciated, a big heartfelt thank you" - Dr. Pramod Jacob

Author
Dr Pramod D. Jacob (MBBS, MS- Medical Informatics)

After completing his medical degree from CMC Vellore and doing his Master of Science in Medical Informatics from Oregon Health Sciences University (OHSU) in the US, Dr Pramod worked in the EMR division of Epic Systems, USA and was the Clinical Systems Project Manager in Multnomah
County, Portland, Oregon. He went to do Healthcare IT consultancy work for states and counties in the US and India.

At present he is a Director and Chief Medical Officer of dWise Healthcare IT solutions. He was also a consultant for WHO India in the IDSP project and for PHFI for a Non Communicable Diseases Decision Support Application.

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