NCD SURVEILLANCE step up surveillance

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Thank you Dr. Farouq. I would like to thank Dr. Rajesh for having invited me here and
given me this opportunity to speak at this 31st Annual conference. The IAPSM
conference has always been an important conference as far as the PSM faculty and
students are concerned, and this particular conference is more important because of the
theme that has been identified. Even more important is the word ‘networking’ that has
been put into this. We have been working independently and alone for a long time. As
many of you have seen since the morning presentations, and, especially the plea that Dr.
Banthia made on behalf of the Registrar General’s office, of how much important it is for
us to interact and work together to be able to attain anything that we need to. Even here,
we are talking separately of communicable and non-communicable diseases, but
eventually, we will have to work towards integrating this. Non-communicable diseases
themselves have a lot of networking and integration that they need to do within their own
different disease spectra and physiology as well as clinical presentations. More
importantly, the risk factors for these several chronic diseases are common. I am going
to be covering some of these aspects in the talk. All of you are aware of how the
projected increase in non-communicable diseases globally has been shown through
various WHO’s reports and how even India is going to be facing the same pattern of
increase as is shown globally. We can see that cardiovascular diseases as a cause of
mortality will become number one very soon and neoplasms and injuries are not very far
behind. In view of the high prevalence of tobacco use in our country, in the region of
South-East Asia Region of WHO, we really need to work upon this problem much more.
About tobacco cessation, we now have information about how many have quit smoking.
We find only 2% to 3% of smokers actually quit smoking in our country. So, we have to
concentrate on lifestyle promotion at a younger age group to be able to get less people to
take up the habit rather than putting more effort and energy in making them give up the
habit. The World Health Organisation in its World Health Report has shown the global
distribution of blood pressure, which, for India is 2% to 4% of DALY’s that are lost due
to blood pressure-related morbidity. Proportion of DALY’s related to cardiovascular
diseases is increasing as years go by, and we have to prepare ourselves for this epidemic.
Similarly, to focus on what has been the current WHO’s emphasis on weight and obesity,
mortality due to obesity although lower in developing countries at present, is going up.
Within our own country’s specific data we can see how the MI has doubled both in males
and has more than doubled in females in less than 10 years of time gap. Lets look at what
the surveillance needs are. As far as the definition is concerned, it has been covered up
earlier but just for repetition’s sake, the emphasis has to be on information for action. We
have spent a lot of our time even in the past, on collection of information and making
some use of it. A bigger drawback here, so far, has been on how to assess it and utilize it
in our control programmes. We do have several uses of surveillance data and we need to
put them to appropriate use. As far as non-communicable diseases and mental health as
well as injury surveillance is concerned, it comes under the overall umbrella of
population measures that are to be adopted and these are factors to be considered for the
monitoring and evaluation of health promotion and disease prevention programmes. This
provides valuable inputs to the overall health information system of the country. The
non-communicable disease surveillance strategy is basically aimed at this triad which
initiates with the behaviour risk factor which lead to physiological changes; increase in
blood pressure, high blood glucose and cholesterol, and end up with disease outcomes,
i.e. heart disease, stroke, respiratory diseases and cancers. The focus on non-
communicable diseases has been on risk factors for the reason that they are amenable to
intervention or much simpler to collect information upon, especially when considering
surveillance mechanisms. We do have standard definitions which sometimes, for disease
purposes, becomes difficult when you go into the community. We also have validated
measures that can be used in a comparable way. The risk factors for these four common
illnesses are common and it makes our task so much easier when we are looking at
intervention strategies.

         In our country, we have various sources of data collection, whether it is in terms
of death certification, or special morbidity data collection. We do have registries for
cancer, and some special surveys, but by and large, the issue of burden of diseases for
non-communicable diseases has not been extensively studied. The WHO and ICMR
have started one programme wherein we are trying to collate the information after having
held a national workshop on this topic. There is piecemeal data available from several
individual publications. We will try and put that up in to a monograph and based on that,
we will provide some suggestions and recommendations, on how to go further into this
very important issue of the burden of the disease for non-communicable diseases. Some
of the current surveillance activities have been presented earlier such as the NFHS data
that Dr. Cherian showed. Cancer registries, have been, for all practical purposes, the only
longstanding surveillance programme in our country. It was started by ICMR in 1980s
and by now, apart from these 11 registries under the ICMR, there are several other
registries, other hospitals which have started registries on cancer, either hospital based or
some population-based. The NCRP has been very effective in giving us both national
and international comparable data on incidence, on time trends over at least last 20 years.
Some registries were started later on in 1988, one of Barshi which is a rural registry and
the registry at Bhopal, which was initiated after the gas exposure disaster took place. It
has also provided us information on age specific incidence. The incidence is lower in
rural areas. It also gives us information on actual disease load, which is very important
for policy makers and for programme activities. The registries also provided us
information on most common cancers. Tobacco-related cancers come in No. 1 or No. 2,
and this information is very important for policy and decision making. Similarly,
amongst women, we have not only the information on the top most common sites but also
on the changes over time. Amongst women, cervical cancer was common in all registries
except at Bombay where breast cancer was No. 1, when we started with the registries 20
years ago. Today, breast cancer in women is No. 1 at Bangalore and at Delhi. So these
registries are also providing us changes in the trend and in the pattern of disease, which is
again providing very important inputs on how the programme management should direct
its activities.

A more recent development has been with the help of WHO, the initiative on sentinel
health monitoring for non-communicable disease risk factors, which we hope, will form a
vital component of the country’s health system and will facilitate programme
implementation. One of the important problems that we face when we started this
programme was the differences that exist in our country, both in terms of habits, different
dietary habits, as well as the urbanization and development that takes place. We selected
five different centers in order to address some of these issues with overall goal to develop
a system for surveillance for non-communication in India and setting up regional centers
which could then act as networking centers for the rest of the country. The centers we
have selected have been in different parts of the country, based upon the availability of
infrastructure and expertise and agreement for participation. They also represent different
types of health care system that is being provided in the country which includes private,
government, rural, and an ICMR center which have been included. We are taking the
four risk factors of tobacco, alcohol, diet, and physical activity and the measurements
include blood pressure, pulse rate, and waist circumference. The Stepwise approach
recommended by WHO has been adopted for collecting this information. The Step One
looks at questionnaire-based information, Step Two looks at measurement, and Step
Three looks at biochemical tests. At each step you have three different types of
questionnaires. Today, more than 30 countries across the world are participating in this
study. In our country, we have added tobacco chewing as one of the optional
questionnaire. The core questionnaire and step one looks at the demography, tobacco,
alcohol, nutrition and information on physical activity, which has still been difficult for
us to calculate. We have been using some of the questionnaires that have been
developed by WHO, adapted to our settings, but a lot still more needs to be done to fine
tune this. We have not started Step Three, which we hope we will take up subsequently,
either this year, or try and see how we can work out the operational modalities. We are
taking both rural and urban population in all of these centers. One of the Centers is also
focusing on behavioural risk factors so as to understand why people put themselves at
this increased risk of having adopted such behaviour which they know are contributing to
the disease.

        Another example of surveillance programme that has been going on in our
country is the industrial population surveillance study, which Dr. K.S. Reddy at All India
Institute of Medical Sciences has initiated in 10 major industries, in collaboration with
the Confederation of Indian Industries, the Ministry of Health, and WHO and they have
looked at all the risk factors for cardiovascular diseases specifically and have now gone
further into implementation of intervention programmes. The programme looks at
continued surveillance and health education.

Just as an example, I have taken one slide from Dr. Reddy’s presentation to show the
distribution of the BMI, again focusing on obesity and as you can see, even if we take the
cut off of 27 which is really high, we still have a fairly large population already obese.
This becomes very important for all of us working in Community Medicine area, when
we are tackling undernutrition and malnutrition on one side and to tackle the other
extreme of obesity which is emerging so rapidly in our country.

The integrated disease surveillance programme has been talked about earlier but I would
like to focus on the NCD component of that. We will follow a slightly different pattern
for NCD, mainly because, we are going to go through a much longer process of change
that can take place. It does not happen overnight, and we are not expecting it within a
month. So the monitoring is not going to be done on continuous basis over whole year, it
is going to be done in a short span of period, a cross-sectional survey which will be
repeated every three years or five years, depending on the operational feasibility that we
will work out, and such repeat surveys will provide us information on time trends. The
biochemical parameters is again an issue that we need to work out and the role of private
laboratories in this is going to be a very important one in view of limited government
infrastructure available for diagnosis and providing of such facilities. The ICMR and the
Ministry of Health are also working on the diabetes control programme to evolve some
guidelines, which can be at the primary health care level, with minimal requirements for
diagnosis of diabetes in the periphery and the primary health care level. So, looking at
the surveillance system, this slide shows the interaction of how, starting with research, we
go on to establishing the surveillance mechanism, which will have a very strong influence
on health policy and programme making, and we will also help in evaluating these
through constant surveillance, and the information that is generated will provide inputs
for research, surveillance activities and also for programme activities. And of course, we
have several users of surveillance data. Importantly, I just want to focus on the collateral
agencies which hasn’t been talked about, who will benefit a lot from this and their role
and involvement becomes important for us.

Some of the suggestions that I had in mind were mainly, looking at integrating national
surveillance programme because, whenever, (as all of you know) we go into the
community level or individual at the village level, it does not differentiate between a
communicable or a non-communicable disease and the worker or health programme
implementer is one person, as far as that consumer is concerned. We do need to look at
high risk populations if possible, and some data from national family health survey has
given us inputs at least on tobacco use and some other factors, and we want to explore
using medical colleges. I want to appeal to all of you to see how much of infrastructure
can be made available for such activities from your own medical colleges, using your
students and interns who can be made part of such a surveillance mechanism, because
one of the biggest drawbacks and difficulties that we are having in this implementation is
to make it self-sustainable. It is difficult to provide long term funding for such
programmes and we do need to look at various alternatives that will make such an
activity continuous without burdening the ex-checker in a major way. The surveillance
activities are also going to be used towards developing more national health programmes
for non-communicable disease that we still want the government to develop. We have
evolved the outline for cardiovascular, diabetes, and stroke programme. We were unable
to get this through because of financial crunch that the government is facing. We hope
we will able to do that in the near future. To end, the key messages are that we need to
recognize the emerging epidemic of non-communicable diseases, look at the effective
interventions which are available today, developed partnerships, evolve the surveillance
system and link them to the policy and planning.

       Thank You.

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