31st Annual National Conference of IAPSM, Chandigarh 27-

29 February 2004 Non Communicable Diseases Non Communicable Diseases

Surveillance in IndiaSurveillance in India

Dr. Bela ShahSr. Deputy Director General

Division of Non-communicable DiseasesIndian Council of Medical Research

New Delhi

Deaths due to Non-communicable and Communicable diseases 1990-2020

India, and World (Males)

5561

6672

3326

2014

41

50.558

66

50

38.530

22

0

10

20

30

40

50

60

70

80

90

1990 2000 2010 2020

Year

World NCD

World CD

India NCD

India CD

ESTIMATED & PROJECTED MORTALITY RATE FOR CAUSES OF DEATH (PER 100,000)

BY SEX, INDIA

1985 2000 2015 M F M F M F

All causes 1158 1165 879 790 846 745 Infectious 478 476 215 239 152 175 Neoplasms 43 51 88 74 108 91 Circulatory 145 126 253 204 295 239 Pregnancy 0 22 0 12 0 10 Perinatal 168 132 60 48 40 30 Injury 85 65 82 28 84 29 Other 239 293 280 285 167 171

(Source : World Bank Health Sectorial Priorities Review)

Mortality by cause in India-1990 & 1998NCDs emerging as major causes of mortality

0

500

1000

1500

2000

2500

3000

1990 1998

Burden of risk factors

Smoking Prevalence by WHO Regions, 1998

Male

Female

World 1998: 1,235,000,000 smokersEstimate 2020: 1,670,000,000 smokers

36.2%

9.4%

34.7%

23.0%

43.8%

23.4%

34.2%

8.7% 48.2%

8.2%

62.3%

5.8%

DALYS (‘000) FOR CARDIOVASCULAR DISEASES IN

INDIA DURING 2000-2020

28500

34929

43524

1593820907

27788

125631402215736

05000

1000015000200002500030000350004000045000

Total Males Females

2000 2010 2020

Source: The Global Burden of Disease by CJL Murray and AD Lopez, WHO 1996

Attributable Mortality & DALYs by Overweight

Mortality (%)

1.1

4.2

9.6

2

5.6

11.5

0

2

4

6

8

10

12

14

HMD LMD Develop

Male Female

DALYs lost(%)

0.6

2.3

6.9

1

3.2

8.1

0

1

2

3

4

5

6

7

8

9

HMD LMD Develop

Male Female

World Health Report 2002

Rising Prevalence of Obesity in Urban India

BMI >27 kg/m2

11.2

22.3

13.2

29.7

0

5

10

15

20

25

30

Male Female

19942001

Gupta et al, IHJ 2002

Surveillance needs for

NCDs

What is surveillance?What is surveillance?

Surveillance is the ongoing collection, analysis, and use of health data for the

planning, implementation, and assessment of disease control

"information for action”

Surveillance needs for NCDs

• Identify extent of the problem

• Map emerging patterns and trends

• Measure progress in primary prevention

• Contribute to policy making

Uses of surveillance dataUses of surveillance data

Surveillance needs for NCDs

Surveillance - essential for health policy

NCD/MH/Injury

Surveillance

Monitoring Evaluation of HP/DP Programmes

Health Information System

Surveillance population measures

Strategy for NCD surveillanceStrategy for NCD surveillance

DiseaseDisease OutcomesOutcomes

Heart disease Stroke

Diabetes Cancer

Respiratory

DiseaseDisease OutcomesOutcomes

Heart disease Stroke

Diabetes Cancer

Respiratory

Physiological RFPhysiological RF BMI Blood pressure Blood glucose Cholesterol

Physiological RFPhysiological RF BMI Blood pressure Blood glucose Cholesterol

Behavioral Behavioral RFRFTobaccoAlcoholPhysical inactivity

Nutrition

Behavioral Behavioral RFRFTobaccoAlcoholPhysical inactivity

Nutrition

The causal chain

… selected risk factors associated with major NCDs and amenable to interventions.

… simple surveillance systems.

… standard definition and methods.

… surveillance for primary prevention of NCDs.

NCD Risk Factor Surveillance: FocusNCD Risk Factor Surveillance: Focus

Rationale for selecting risk factors

Greatest impact on NCD mortality and morbidity;

Modifiable by intervention; Validated measurement; Meaningful comparisons possible; Measurement can be obtained following

ethical standards.

The WHO STEPS approach

Risk factors common to major noncommunicable conditions

ConditionRisk factor

Cardio-vasculardisease*

Diabetes Cancer Respiratoryconditions**

Smoking

Alcohol

Nutrition

Physical inactivity

Obesity

Raised blood pressure

Blood glucose

Blood lipids

SOURCES OF SURVEILLANCE DATA COLLECTION FOR NCDs

in India• Mortality Data

– Medical Certificates for Death– Cause of Death Survey– Hospital Records

• Morbidity data– Registry- Cancer– Special Surveys– Hospital Reports

• Risk Factors– Special Surveys

Current Surveillance Activities

Disease Control Programs• NPSP

• HIV/AIDS

• TB

• Malaria

• Leprosy

NPSCD (National Program for Surveillance of Communicable Diseases)

Other routine Surveillance Activities

NFHS-National Family Health Survey

NSSO-National Sample Survey Organization

Census of India

Ongoing regular periodic surveys

Network of National Cancer Registry Programme

Population Based Cancer Registries

• Mumbai• Bangalore• Chennai• Delhi• Bhopal• Barshi (rural)

Hospital Based Cancer Registries

• Thiruvananthapuram

• Dibrugarh

• Mumbai

• Bangalore

• Chennai

Age-adjusted rate (per 100,000) All cancers, 1997

0 50 100 150 200 250 300 350 400

Bangalore

Bhopal

Chennai

Delhi

Mumbai

Barshi

Connecticut, USA

Oxford, UK

Reg

istr

y

Males Females

Trends in Age standardized Cancer Incidence Rates among Men in India (1982 to 1994)

0

20

40

60

80

100

120

140

160

19821983

19841985

19861987

19881989

19901991

19921993

1994

Age S

tandardized Incidence Rate

Bangalore Mumbai Chennai Delhi Bhopal Barshi

AGE SPECIFIC INCIDENCE , 1997. ALL CANCERS, MALES

0

200

400

600

800

1000

0 10 20 30 40 50 60 70 80AGE-GROUP(YEARS)

INC

IDE

NC

E P

ER

10

0,00

0

BANGALORE BARSHI BHOPAL CHENNAI DELHI MUMBAI

National Cancer Registry Programme1997

Incident Cancer Cases in India

Year Incident Cases

1992 644,600

2001 806,000

Common Cancers among Men in India1997 according to Crude Incidence Rate

Rank Bangalore Bhopal Chennai Delhi Mumbai Barshi

1 Stomach

5.0

Lung

14.5

Stomach

9.6

Lung

7.4

Lung

6.4

Hypophar

3.9

2 Oesophag

4.0

Mouth unspeci

4.7

Lung

8.3

Larynx

5.3

Oesophag

4.3

Oesophag

3.5

3 Lung

3.7

Tongue

4.6

Oesophag

6.7

Prostate

3.6

Larynx

3.7

Liver

3.1

4 Hypophar

3.1

Oesophag

4.5

Tongue

4.3

Brain

3.4

Tongue

3.7

Mye Leuk

2.3

5 Prostate

2.1

Hypophar

3.3

Prostate

4.0

Tongue

3.2

Prostate

3.5

Penis

1.9

Common Cancers among Women in India

Rank Bangalore Bhopal Chennai Delhi Mumbai Barshi

1 Breast

14.8

Cervix 18.7

Cervix

23.6

Breast

19.8

Breast

20.6

Cervix

18.7

2 Cervix

13.8

Breast

12.3

Breast

21.4

Cervix

15.8

Cervix

12.1

Breast

7.5

3 Oesophagus

3.8

Ovary

3.5

Stomach

4.6

Ovary

6.5

Ovary

6.0

Oesopha

2.1

4 Stomach

3.1

Oesophag

2.5

Ovary

4.4

Gall Blad

5.6

Oesophag

3.9

Ovary

2.1

5 Ovary

2.9

Mouth Unspeci

2.5

Oesopha

4.2

Lympho

2.3

Lung

3.0

Gum

1.2

Development of Sentinel Health Monitoring

Centres in India

An ICMR-WHO Initiative

Disease Surveillance

• An Integrated Disease Surveillance System for the country has been a felt need for the country

• It is expected to be the back bone of Public Health System in the country

• Early identification of disease outbreaks & occurrence

• Facilitating resource allocation• Monitoring disease control program

Analyse this Marked Heterogeneity!

Kerala

Delhi

Jammu & Kashmir

Nagaland

Bihar

High literacy rate, developed

Metropolitan city, highly urbanised, heterogeneous population

Nested populationTerrain, relatively underdeveloped

Nested populationUnderdeveloped, Tribes andTerrain

Illiterate, Poor populationRural, Agricultural, Tribals

•Differentdietary patterns

•Differentbody

composition

•Differenthabits

GoalTo develop a sustainable system for NCD Surveillance in India

AimTo set up Regional Sentinel HealthMonitoring Centers for NCDs in India

Following Six centers are carrying out the study, representing 5 Geographic Regions of India

North HaryanaDelhi

CRHSP, BallabhgarhIHBAS, Delhi

South Tamilnadu MDRF, Chennai

East Assam RMRC, Dibrugarh

West Kerela SCTIMS, Thiruvanathapuram

Central Maharashtra GMC, Nagpur

Risk Factors•Tobacco - Current, past, and never. Age of initiation

– Smoking form and nonsmoking form (orally consumed and application forms).

•Alcohol - regular, (age of initiation also) occasional, past, and never. Type of alcohol. Country liquor, IMFL. •Diet- consumption of fruits, vegetables, non-vegetarian food and oil/fat used.•Physical activity- type and degree•Measurements- Blood Pressure, Pulse rate, Waist circumference

Step 3

Comprehensiveness

Co

mp

lexi

ty

Step 2

Step 1Core

Expanded

Optional

The WHO STEPwise approach to Surveillance (STEPS) of NCD Risk

Factors

At each step

The WHO STEPS approach

Levels of Risk Factor Surveillance at each StepMeasures

Level

Step 1

(Verbal)

Step 2

(Physical)

Step 3

(Biochemical)

Core Demographics,Tobacco, Alcohol,

Nutrition,

Physical activity

Measuredweight + height,

Waist girth,

Blood pressure

Cholesterol,

Fasting bloodsugar

Expanded Education,OccupationIndicators,

Hip girth, HDL-Chol,

Triglycerides

Optional Knowledge+attitudes regardinghealth Health-relatedQuality of life andhealth-relatedbehaviour

Skinfolds,Pedometer

Urine, etc.

The WHO STEPS approach

Sample Size

Rural (Male+Female) 3750

Urban (Male+Female) 3750

Total for each Regional Centre 7500

Total for Six Centers(Includes 5000 respondents for IHBAS center)

42500

BEHAVIOURAL RISK FACTORS

“Actions/Behaviour that people engage in that put their health at risk”

NCDs

• Diseases of affluence

• Diseases due to urbanization

• Diseases of developed world

• Chronic diseases

Biobehavioural disorders

HEALTHY WORKPLACESINDIAN EFFORTS

2001-2002 Surveillance of CVD risk factors in 10 major industries across India-

Baseline Survey (in collaboration with CII, MoHFW and WHO)

2003-2004 Development and implementation of health interventions; surveillance of

cause-specific mortality; event registries.

EXTENSIVE BASELINE SURVEY FOR CVD RISK FACTOR AND DETERMINANTS

10 INDUSTRIES TWINNED

WITH MEDICAL COLLEGES

Further surveillance of CVD RF/Determinants for trends

HEALTH EDUCATION AND PROMOTION

COST-EFFECTIVE ALGORITHMS FOR IDENTIFICATION AND PREVENTION OF ACUTE AND CHRONIC CVD

Ascertainment and Monitoring of CVD morbidity and mortality

Study Locations

1. New Delhi

2. Lucknow

3. Ludhiana4. Pune

5. Nagpur

6. Dibrugarh

7. Coimbatore

8. Hyderabad

9. Bangalore

10. Trivandrum

11. Chennai (affiliate center)

Coordinating Center: New Delhi

Study Centers:

Distribution of BMI in Industrial Population Sentinel

Surveillance study

BMI (kg/m2) Male Female

• >23 58.9 63.5

• >25 34.7 43.3

• >27 16.7 26.7

The Concept of IDSP

• Decentralized

• Integrated

• Action oriented

• Bring together both the communicable and non communicable diseases under one surveillance activity.

Background of IDSP

• World Bank funded project through MoH&FW

• Surveillance of infectious and Non- communicable (NCD) diseases share common infrastructure, processes and personnel

• A coordinated approach to data collection, analysis, interpretation and dissemination will facilitate planning and implementation of intervention programs.

DGHS(Co-Chair)

NPO(Cancer, MH)

IMA

NGO

Consultants

Rep.Min Environment NSO

(Member Secretary)

Rep.MOH

DirectorNIB

DirectorNICD

JS(FA)

JS(Welfare)

JS(Health)

DG, ICMR

National Surveillance* Committee

* Chairperson: Secretary Health or Secretary Family Welfare (to alternate)

Organogram National Surveillance Committee

Director HealthServices

State Program Officers

Data ManagerIDSP

Head StatePublic Health

State Trainingofficer

Environment

IMASSO

(Member Secretary)

Min. Home

State coordinator

Medical colleges

NGO

Water board)

DME)

Director (PH)Co-Chair

State Surveillance* Committee

* Chairperson: State Secretary Health

Organogram State Surveillance Committee

Aims of IDSP- NCD risk factor surveillance

1. Monitor trends of important risk factors of NCD in the community over a period of time

2. Evolve strategies for interventions of these risk factors so as to reduce the burden of diseases due to noncommunicable diseases

3. Strengthen NCD surveillance at District level4. To integrate the NCD risk factor surveillance with

IDSP 5. Evolve a data bank

Partners

• Ministry of Health & Family Welfare

• ICMR

• IndiaCLEN

• World Bank

• WHO

• State & District level Surveillance Officers

Research Surveillance Health Policies and programmes

Information

influence

evaluate

Characteristics of a surveillance system

Suggested Strategies for NCD SURVEILLANCE in India

• Integrated national surveillance programme

• Include Comm. Disease and Selected NCDs/ Risk Factors

• Identify populations for development of NCD Risk Factor surveillance module

• Utilize medical schools/ students for implementation

SUGGESTED STRATEGIES for NCD SURVEILLANCE in INDIA

• Initiate National level control programmes

• Establish govt. policies for programme implementation

• Encourage surveillance for NCDs

• Incorporate findings of surveillance into national programmes for Intervention

USERS OF SURVEILLANCE DATA

• Policy Makers & Programme implementors

• Researchers and Public Health specialists

• Collateral agencies- food manufacturers, sports equipment,tobacco industry

• Public, Media

• Associations, Universities

• Donors, private medical services

Key messages

• Recognize the emerging epidemic

• Effective interventions exist

• Partnerships to implement existing knowledge

• Set surveillance systems in place now,

focus on risk factors

• Use a stepwise approach

• Link to policy and planning

Current status of implementation of NCD prevention and control programmes in

SEAR CountriesCountries Tobacco

controlCVD Cancer Diabetes Integrated

control of NCDs

Bangladesh 1982 1978

Bhutan

DPR Korea 2000 2000

India 2000 1975

Indonesia 1989 1995

Maldives 2001

Myanmar 1982 1982 1996 1993

Nepal 1999 1998

Srilanka 1999 2000 2000

Thailand 1988 1988 1988 1988 1993

Note: Shaded areas indicate existence of a plan and the year of implemenation

Source:Non-Communicable Diseases in South-East Asia Region, A Profile, WHO, 2002

Source of NCD related data on the member countries in the region 

Mortality Medical Certifictn of DeathIndia MyanmarSri LankaThailand

Cause of death surveysDPR KoreaIndiaIndonesia

Hospital data All countries except Maldives

MorbidityDisease Registries

India (cancer)Indonesia (cancer)Thailand ( injury)Sri Lanka (cancer)

Special SurveysBangladesh DPR Korea IndiaIndonesia MaldivesMyanmar Sri Lanka

Hospital reports All countries except Maldives

Risk Factor DataRegular Surveys

Indonesia

Special Surveys

BangladeshIndiaSri LankaThailand

No information obtainedBhutanDPR KoreaMaldivesMyanmarNepal

Prevention and management of NCDs

• Generating a local information base for action• Establishing a programme for promotion of health

across life span• Tackling issues outside the health sector which

influence prevention and control of NCDs• Ensuring that health sector reforms are responsive

to the challenge