NCD SURVEILLANCE Dr. BELA SHAH: 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.