RIHFW Kashmir

Disease Surveillance Activities

Despite commendable progress made in the public and private health delivery systems, rural areas, where more than 70% of the country’s population lives, continues to reel under the enormous burden of disease, mainly communicable. Accordingly communicable disease continues to be the most important cause of mortality, morbidity, and disability in India. While the diseases of poverty, ignorance and social inequity (viz infections and infestations, lack of perinatal services, unregulated fertility, and malnutrition)

continue to flourish in the rural as well as slum areas, diseases resulting from adoption of unhealthy behaviours - heart disease, obesity, diabetes, STD/HIV – are increasing at an unexpectedly rapid pace especially in the urbanized, industrialized parts.

Over the last few decades it has dawned upon the health providers that the emerging and re-emerging problems may catch us unawares – be it a plague outbreak or heart disease among the young adults. This is because no effective disease surveillance system has been in place in the country. In April 1996, the Government of India appointed a National Apical Advisory Committee which recommended formulation of a comprehensive National Disease Surveillance and Response System to be developed at district level, all over India by 2003. The Programme has to remain decentralized so that all surveillance and response activities are performed at district level (by the district epidemiology cell), with the State Epidemiology Centre coordinating the activities at the State level and the National Institute of Communicable Diseases, New Delhi, at the Central level.

The 3 important components of the National Disease Surveillance and Response System are recognition, reporting and response. For prompt recognition of emerging problems or changing trends quality of diagnosis has to be improved by upgrading clinical and technical skills of the staff and improving the district laboratory facilities. Timeliness and completeness of reporting has to be assured by building an effective health information system for which the concerned workers have to be sensitized, oriented, and trained. The 3 rd pillar of the Surveillance System is the response which, in turn, entails information feed back, investigation for etiology and interventions for control, the speed and effectiveness of all these needs to be improved if the Programme has to make any significant difference.

In 1999, the National Disease Surveillance Programme was only marginally extended to our State, however, in that year, a Disease Surveillance Section was established in the RIHFW, Dhobiwan, being manned by qualified public health specialists. In the first place a new disease reporting form (cases and deaths) was devised as a modification to the WHO’s ICD-10 form to make it comprehensive but at the same time simple. All the BMO's were oriented to the proper filling of the forms. The idea is that the BMO consolidates the information received from the medical establishments in his block, sends one copy directly to the Disease Surveillance Section and the other copy to his CMO who consolidates the information from his district. The Disease Surveillance Section at

Dhobiwan analyses the data received from the block, monitors the trends, and provides monthly feedback directly to the BMO to take immediate action wherever and whenever needed. This ensures decentralization in its truest sense, since reporting as well as response are quicker in pace and nearer to the scene of action than previously ever possible. This, on the one hand, provides opportunity to the peripheral workers for a full involvement , and, on the other, helps to focus immediate attention where it is needed most. Previously unaccustomed to a scientifically-sound surveillance system, progressively increasing number of BMO's are eagerly participating in the new Disease Surveillance and Response System. In addition, two blocks from each district have been taken up to develop bilaterally interactive weekly reporting-response system. The Bijbehara block in the Anantnag District has been providing regular, uninterrupted weekly data on water-borne infections since 1999.

In 2003, two districts (Kupwatra and Leh) have been taken up under the National Disease Surveillance Programme (which is now rechristened the Integrated Disease Surveillance Programme). Training of medical officers and paramedics has been completed in Kupwara. (see above). The surveillance data is being electronically transmitted to the National Institute of Communicable Diseases through the coordinators at the Disease Surveillance Section.

Various outbreaks of acute diarrhoeal disease, hepatitis and enteric fever have been investigated by the Disease Surveillance Section which has revealed presence of hepatitis E in every district of Kashmir Valley, and excluded presence of cholera in most outbreaks of diarrhoea. The investigations have also revealed that the underlying cause of endemicity (with occasional outbreak potential) of water-borne disease is scarcity of

safe, potable water. Diphtheria outbreaks occurred in two districts (Baramulla, Srinagar) in 2002 and in Hindwara block (of District Baramulla) in 2003. The former outbreak had started from Sheri block of district and reached Srinagar, while as the latter outbreak remained confined to 2 villages of health block Bandipur. The National Institute of Communicable Diseases, Delhi, helped in containing the latter episode.

A number of workshops have been held for the CMO's, DHO's and BMO's to orient them to the most pertinent public health problems. Analysis of the reported data reveals that the diarrhoeal disease is the main cause of morbidity among children followed by acute respiratory infection; diarrhea shows a definite seasonal increase from June till September, and that typhoid fever is revealing a biphasic trend. There has been no confirmed case of poliomyelitis in the Kashmir Division since 1997. Among the non-communicable diseases, hypertension affects about 15% of the adult population. Community-based studies about other Non-Communicable Diseases's are unconvincing. It is hoped that as the reporting of disease and deaths gets streamlined with enthusiastic participation of the district health staff, the reported data will become more reliable and thus worthwhile for planning and policymaking.

There is no doubt that huge inputs in the form of manpower, information network (computers, software), vehicles, POL, laboratory backup etc, are required for better surveillance activities. In the last year 2 districts (Leh and Kupwara) were taken up for inclusion into under the National Disease Surveillance and Response System with release of funds for training of doctors and paramedics. Soon infrastructural up-gradation is being undertaken in these districts. The nodal provincial agency for coordinating surveillance activities will be the Regional Institute of Health and Family Welfare, Dhobiwan.

My sincere thanks to Ms Neelam and Mr Rauf Ahmad Wani for diligently computing the script.