Surveillance & IDSP

SURVEILLANCE & IDSP
SESSION 10
Dr Dipayan Banerjee
The National Institute of Health and Family Welfare
ONLINE TRAINING PROGRAMME ON BASIC AND APPLIED
EPIDEMIOLOGY

CONTENTS
 SECTION 1 : Surveillance
 Part 1 : Introduction
 Part 2 : Types
 Part 3 : Uses
 SECTION 2: IDSP
 IHIP
 SECTION 3: Special Surveillance
 SECTION 4:COVID-19 Surveillance

PUBLIC HEALTH SURVEILLANCE
“Ongoing, systematic collection, analysis, interpretation, and
dissemination of data regarding a health-related event for use
in public health action to reduce morbidity and mortality and
to improve health.”
- CDC. Updated guidelines for evaluating public health surveillance systems. MMWR 2001;50 (No. RR-13)
CDC. MMWR 2001; 50: RR-13

Problem Response
Surveillance:
What
is the
problem?
Risk Factor
Identification:
What is the
cause?
Intervention
Evaluation:
What
works?
Implementation:
How do you
do it?
PUBLIC HEALTH APPROACH

BROAD GOAL OF PUBLIC HEALTH SURVEILLANCE
Provide actionable health information to public health staff,
government leaders, and the public to guide public health
policy and programs
Smith PF et al. “Blueprint Version 2.0”: Updating public health surveillance for the 21st
century. J Public Health Management and Practice, 2012

SPECIFIC GOALS OF PUBLIC HEALTH SURVEILLANCE
To portray the ongoing pattern of health-
related states and events, to…
 Assess public health status
 Trigger public health action
 Define public health priorities
 Evaluate programs
“Information for Action”

TYPES OF SURVEILLANCE
 Case-based (individual) vs. aggregate
 Passive vs. Active
 Population-based vs. Sentinel
 Disease-specific vs. Syndromic
 Indicator-Based Surveillance (IBS) vs. Event-Based Surveillance
(EBS)

TYPES OF SURVEILLANCE
 Passive: Cases are reported to a health facility
 Usually adequate for monitoring trends over time, place, person
 Advantages: efficient, simple and requires few resources
 Disadvantage: underreporting (incomplete data)
 Active: Health worker goes to community looking for cases
 Usually reserved for diseases of special interest, e.g., SARS, TB
 Most public health surveillance systems are passive

SENTINEL SURVEILLANCE
 Surveillance based on selected population samples
chosen to represent the relevant experience of particular
groups
or
Reporting of health events by health professionals who
are selected to represent a geographic area or a specific
reporting group
 Can be active or passive surveillance

SENTINEL SURVEILLANCE: CHARACTERISTICS
 Selected physicians or facilities involved
 Specified diseases reported
 High quality data collected
 Lack of representativeness
 Useful for common conditions where
 Complete case counting is not important
 Public health action is not taken in response to individual reported
cases
 Done for HIV, HBV, HCV, Outdoor air & water quality

SYNDROMIC SURVEILLANCE
 Syndromic surveillance – focuses on one or
constellation of symptoms rather than diagnosed
disease
 Examples
 Acute diarrheal diseases
 Acute respiratory infection

TABULATION / ANALYSIS OF SURVEILLANCE DATA
 Descriptive – most common
 Time
 Place
 Person
 Analytic methods
 Time-series analyses to detect aberrations
 Time-space clustering

0
5
10
15
20
25
21 24 27 30 2
Cases
S-FORM REPORTED JAUNDICE CASES, 2011-13
Distribution of ADD Cases by Onset of Symptoms,
Udaipur, Oct-Nov 2014 (N=83)
Distribution by Time

Distribution by Place
• Where reported (usual method)
• Where exposure occurred
(preferred)
• Allows prevention resources to be
targeted effectively
• Use of computers and spatial
mapping software allows for
sophisticated analysis

DISTRIBUTION BY PERSON
• Demographics
• Age
• Sex
• Religion
• Occupation
• Risk factors, if collected
• HIV risk group
• For vaccine-preventable diseases, vaccination status

DATA INTERPRETATION: WHY AN APPARENT INCREASE IN CASES?
 Change in reporting procedures / change in surveillance system
 Change in case definition
 Improvements in diagnostic procedures
 Increased awareness
 Increased access to health care
 New physician or clinic – may see more cases, may make diagnosis more
often, or report more consistently
 Batch reporting
 True increase in incidence

DISSEMINATION OF SURVEILLANCE DATA
To Whom?
 Public health officials
 Governmental officials
 Clinicians / labs (reporters)
 Public

USES OF PUBLIC HEALTH SURVEILLANCE
 To Recognize cases or cluster of cases to trigger interventions
to prevent transmission or reduce morbidity and mortality.
 To Assess the public health impact of health events or
determine and measure trends.
 To Demonstrate the need for public health intervention,
programmes and resources and allocate resources during
public health planning.
 To Monitor effectiveness of prevention and control measures.

CONT.………..
 To identify high-risk groups or geographical areas for target
interventions and guide analytic studies.
 To develop hypothesis that lead to analytic studies about risk
factors for disease causation, propagation or progression.

INTEGRATED DISEASE SURVEILLANCE PROGRAMME
 Integrated disease surveillance project is a decentralized, state-
based surveillance system in the country.
 IDSP is intended to detect early warning signals of impending
outbreaks and help initiate an effective response in a timely
manner.

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)
 2018: Phased integration and implementation of IHIP

PHASED IMPLEMENTATION OF IDSP
 Phase I [commencing from 2004-05]
 Andhra Pradesh, Himachal Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Uttaranchal, Tamil Nadu,
Mizoram & Kerala
 Phase II [commencing from 2005-06]
 Chhattisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Meghalaya, Orissa, Tripura,
Chandigarh, Pondicherry & Delhi
 Phase III [commencing from 2006-07]
 Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland,
Sikkim, A&N islands, D&N Haveli, Damon & Diu & Lakshadweep

OBJECTIVES OF IDSP
 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 programs and other stake
holders so that valid data is available for health decision making in the
district, state and national levels

STRATEGY FOR SURVEILLANCE IN IDSP
 District level is the basic functional unit for integrating surveillance functions
 All surveillance activities are coordinated and streamlined
 Resources are combined to collect information from single focal point at each
level
 Integrates both public & private sectors with emphasis on community
participation
 Integrates communicable and non communicable disease
 Integrates both rural & urban health system
 Integration with medical colleges both govt and private
24

ORGANIZATIONAL
STRUCTURE
 Centre
 State
 District

INDICATOR-BASED SURVEILLANCE (IBS)
 The collection of IBS data is a routine, regular process which is
primarily passive.
 Data are collected according to established case definitions.
 May be collected as individual or aggregated data.
 Data are analysed in comparison with baseline values and
thresholds to determine unusual disease patterns.

EVENT-BASED SURVEILLANCE (EBS)
Event-Based Surveillance (EBS) consists of mainly:
 Unstructured ad hoc information regarding health events which may
represent an acute risk to human health.
 It is a functional component of EWAR.
 Information collected for EBS is diverse in nature - originates from
multiple, often not-predetermined sources .
 Information collection process is active - carried out through a systematic
framework specifically established for EBS purposes.

OUTBREAK INVESTIGATIONS
An outbreak or epidemic is defined as the occurrence in a
community of cases of an illness clearly in excess of
expected numbers. While an outbreak is usually limited to a
small focal area, an epidemic covers large geographic areas
and has more than one focal point.

EWS / OUTBREAK REPORTING FORM
 State SSU need to
report
instantaneously as
well as weekly
compilation on
every Monday to
the CSU including
NIL reports.

MEDIA SCANNING AND VERIFICATION CELL
To strengthen the event based surveillance system under IDSP, media scanning and
verification activity was initiated for screening/scanning of unusual health events through
media for generating early warning signal for outbreaks.
Outline of Media scanning and verification:
 Source and collection of information (unusual health events)
 Identification of media alerts
 Alert verification
 Response to the media alert
 Monitoring

SURVEILLANCE UNDER IDSP
 Syndromic: Syndromic surveillance is defined as the surveillance of diseases
based on the presenting symptom/s (and not the disease attributable to the
syndrome).
 Diagnosis made on the basis clinical pattern by health workers, village volunteers and non-formal
practitioners.
 Presumptive: Presumptive surveillance is defined as the surveillance of diseases
based on the probable medical diagnosis of the presenting syndrome/s.
 Diagnosis is made on typical history and clinical examination by medical officers
 Laboratory confirmed: Confirmed Case is a clinical case with positive laboratory
confirmation by appropriate laboratory test/s. Three different forms (L1, L2, L3)

S FORM
 Fever less than 7 days: Only fever; fever with rash; fever with bleeding; with
dizziness or unconsciousness
 Fever more than 7 days
 Cough with or without fever: less than 3 weeks, more than 3 weeks
 Loose watery stools of less than 2 weeks duration: with some/much dehydration,
with no dehydration, with blood in stool
 Jaundice: <4weeks
 Acute flaccid paralysis in less than 15 years of age
 Unusual symptoms leading to death/hospitalization (not fitting in above)

 Acute diarrheal
diseases
(including AGE)
 Biliary dysentery
 Viral hepatitis
 Enteric fever
 Malaria
 Dengue/DHF/DS
S
 Chikungunya
 Acute
encephalitis
syndrome
 Meningitis
 Measles
 Diphtheria
 Pertussis
 Chickenpox
 Fever of unknown origin (PUO)
 Acute respiratory infection/ILI
 Pneumonia
 Leptospirosis
 AFP
 Dog bite
 Snake bite
 Any other state specific diseases
 Unusual syndromes not captured above
P FORM

STATE SPECIFIC DISEASES
Diphtheria, NN Tetanus, leprosy Madhya Pradesh / Uttaranchal
Diphtheria, NN Tetanus, leptospirosis Maharashtra
Filariasis, KFD & HGS, leptospirosis Karnataka
Leptospirosis, leprosy Tamil Nadu
Leptospirosis Kerala
Cancers, substance abuse,
pneumonia, acid peptic disease
Mizoram
Filariasis Andhra Pradesh

L FORM
 Dengue/DHF/DSS
 Chikungunya
 JE
 Meningococcal meningitis
 Typhoid fever
 Diphtheria
 Cholera
 Shigella dysentery
 Viral hepatitis A, E
 Leptospirosis
 Malaria

WATER SURVEILLANCE
 Form W is meant for the use of Health Workers and Laboratory Personnel at PHCs,
CHCs and in various other laboratories in the district to record the information on
Water Quality from different drinking water sources in the districts.
 At community level: health workers to conduct the Ortho Toluidine test (using
Choloroscopes) of the drinking water sources in the villages.
 At laboratory level:
 H2S test conducted at the PHCs and CHCs and other sub-district laboratories for
checking fecal contamination in drinking water
 MPN test at district laboratories for detection on coliform bacteria in drinking water.

INTEGRATED HEALTH INFORMATION PLATFORM
 Web-enabled near-real-time electronic information system that
is embedded with all applicable Government of India's e-
Governance, Information Technology (IT), data & meta data
standards to provide state-of-the-art single operating picture
geospatial Information for managing disease outbreaks and
related resources.

 Key features of IHIP:
 Real time data reporting (along through mobile application); accessible at all levels (from
villages, states and central level)
 Advanced data modelling & analytical tools
 GIS enabled Graphical representation of data into integrated dashboard
 Role & hierarchy-based feedback & alert mechanisms
 Geo-tagging of reporting health facilities
 Scope for data integration with other health programs
 First phase launched in November 2018 in 7 states: Karnataka, Andhra Pradesh, Himachal
Pradesh, Odisha, Uttar Pradesh, Telangana, & Kerala
 In the 2021 budget the IHIP was proposed to be launched in all the states and union
territories of India

SPECIAL SURVEILLANCE
 Implemented during and after emergency situations like disasters / PHEIC / Mass gatherings for
acquiring more accurate and near real time data
 The time frame for data collection, periodicity, the data entry officials, and specified data elements
differ from the routine IDSP surveillance system
 The decision on activation and deactivation of Special Surveillance is case to case basis and is
taken either at the level of CSU, IDSP or EMR, DGHS.
 Special Surveillance scenarios require mobilization of Human resource, logistics in the affected
area and issuance of technical & administrative guidelines and formats in a short duration of time.
 The data collected by health workers undergo simple descriptive area specific analysis on daily
basis represented either in absolute numbers (cases and deaths) and wherever possible in terms
of morbidity and mortality indicators.

Data Flow
Mechanism
 The main channel of data flow
would be through the existing
IDSP network (Blue)
 Crisis with health consequences
may require reporting directly
from incidence site/district control
room to MoHFW / DGHS / MHA
(Yellow)
 Channels requiring IDSP user IDs
and passwords to view information
(Dotted lines)

NEED FOR SPECIAL SURVEILLANCE SYSTEM THAN THE
ROUTINE SURVEILLANCE SYSTEM
1. Standardized & timely: The time frame for data collection, periodicity,
the data entry officials, and specified data elements differ from the routine
IDSP surveillance system.
2. Coordinated: Involvement of multiple agencies requiring coordinated
efforts for control and management.
3. Interoperability: Situation overwhelms the capacity of State/Central IDSP
unit to tackle it efficiently and needs support from other departments.
4. Avoid duplication of efforts
5. Improves effective communication

PUBLIC HEALTH EMERGENCY OPERATIONS CENTER (PHEOC)
 A Public Health Emergency Operations Center (PHEOC) is a physical location for the
coordination of information and resources to support incident management
activities.
 Goal: To provide single point contact facility for emergency management of Public
Health emergencies.
 Objectives:
1. Act as a command Centre to manage disease outbreaks, public health
emergencies or any disaster situation.
2. Strengthening disease surveillance & response using the latest information &
communication technology

INCIDENT RESPONSE SYSTEM (IRS)
 Effective mechanism for reducing ad-hoc measures in response.
 It envisages a composite team with various Sections to attend to all the
possible response requirements.
 Responsible Officers (ROs) have been designated at the State and District
level as overall in charge of the incident response management.
 The Responsible Officer may delegate responsibilities to the Incident
Commander (IC), who in turn will manage the incident through Incident
Response Teams (IRTs).

POST DISASTER SURVEILLANCE
 Need of special surveillance post disaster:
 Under routine circumstances, these health events may be easily detected and managed,
but during post disaster situation routine services (communication, roads, water
supply and electricity) are thrown into disarray.
 Health care facilities are damaged leading to disruption in routine health care
like immunization.
 Post disaster, relief camps are set up in and around the area till the situation
normalizes. Hence provision of basic public health care like safe water, sanitation and
preventive and curative services is essential.
 Establishment of routine surveillance system with special focus on infectious disease
prone to emerge and spread after disaster is utmost necessary. For e.g., cases of
leptospirosis has been observed to rise after floods due to mixing of cattle & rat urine
with water coming in contact with people.

Syndromes Presumptive diagnoses
1 Loose watery stool 1 Acute diarrheal disease
2 Cholera
2 Loose stool with visible
blood
3 Dysentery
3 Fever 4 Malaria
5 Dengue
6 Chikungunya
4 Fever with bleeding 7 Acute Haemorrhagic
Fever
5 Fever with rash 8 Measles
9 Chickenpox
6 Fever with cough 10 ARI
7 Fever with semi-
consciousness/confusion
11 Acute encephalitis
syndrome
Syndromes
and
Diseases for
surveillance
post
disaster

8 Fever with neck stiffness 12 Meningitis
9 Difficulty in breathing and wheezing 13 Acute Asthma
10 Jaundice (< 4 weeks) 14 Acute Hepatitis
15 Leptospirosis
11 Isolated redness of eyes with or
without discharge
16 Conjunctivitis
12 Open wounds and bruises 17 Open wounds and bruises
13 Fracture 18 Fracture
14 Burns 19 Burns
15 Animal Bites 20
21
Snake bites
Dog bite
16 Drowning 22 Drowning
17 Other (to be specified depending on
the unusual syndrome/event)
24 Other (to be specified depending
on the unusual syndrome/event)

Syndromes Presumptive diagnoses
1 Loose watery stool 1 Acute diarrheal disease
2 Cholera
3 Food poisoning
2 Loose stool with visible blood 4 Dysentery
3 Fever 5 Malaria
6 Dengue
7 Chikungunya
4 Fever with bleeding 8 Acute Haemorrhagic Fever
5 Fever with rash 9 Measles
10 Chickenpox
6 Fever with cough 11 ARI
7 Fever with semi-consciousness/confusion 12 Acute encephalitis syndrome
8 Fever with neck stiffness 13 Meningitis
9 Difficulty in breathing and wheezing 14 Acute Asthma
10 Jaundice (< 4 weeks) 15 Acute Hepatitis
16 Leptospirosis
11 Other (to be specified depending on the unusual
syndrome/event)
17 Open wounds and bruises
18 Fracture
19 Burns
20 Drowning
21 Other (to be specified
depending on the unusual
syndrome/event)
Syndromes
& Diseases
for
surveillanc
e post
Mass
gatherings

SPECIAL SURVEILLANCE FOR COVID-19
 Screening at point of entry
 Thermal Screening of international travelers at various air, land and sea-ports by Port Health Officers.
 Symptomatic cases immediately isolated in hospitals attached to PoE. Asymptomatic travelers allowed
to enter within the country after filling self declaration form.
 Sharing of the details of incoming travelers to Centre/State IDSP Unit
 Source of information: PHOs, Bureau of immigration, Ministry of Civil Aviation etc.
 Daily report shared with stakeholders.
 In country surveillance of the travellers
 Active monitoring of all travelers for any development of symptoms for a period of maximum
incubation period.
 On development of symptoms, case immediately isolated at nearest identified isolation center.
 Sample collected and sent to designated lab for testing
 If negative, managed as per clinician advice, continue monitoring for rest of surveillance period.
 If positive, managed as per confirmed case of COVID19.
 Daily report shared with stakeholders

 Confirmed case of COVID-19
 Case isolated at the designated COVID hospital/home as per criteria.
 Extensive Contact listing and tracing initiated.
 Quarantining of contacts (facility and home as per criteria)
 Testing of contacts as per criteria
 Cluster containment plan
 Delineation of containment zone depending upon number of cases, administrative boundaries,
epidemiological linkages.
 Strict perimeter control
 Daily active ARI Surveillance in the containment zone.
 Testing, isolation & tracing
 Till no more cases detected after double the incubation period.
 Risk communication
 Creating awareness among public to follow preventive public health measures
 Advisory on dos and don'ts
 Hand washing, use of mask and physical distancing
 Precaution for vulnerable and elderly population
 Infodemic management

SUMMARY
 Surveillance is a continuous and ongoing phenomenon
 Analysis & Dissemination of the reports are also important parts of
Surveillance
 Most of the public health surveillances are passive
 Sentinel surveillance is to find out all cases not missed cases
 IDSP works on basis of weekly reporting
 DSU is the basic functional unit for integrating surveillance
functions
 IHIP works on the basis of real-time reporting with GIS tagging
 Special surveillances are implemented during and after emergency
situations like PHEIC/Disasters/Mass gatherings

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