Diseases and outbreaks are reality and a well-functioning system can help reduce their impact.
A defining moment in epidemiological history was the removal of the handle of a water pump. This is a splendid story. In 1854, when a deadly cholera outbreak affected the Soho area of London, John Snow (1813–1858), a British doctor and epidemiologist, used health statistics and death registration data from the General Registrar’s Office (GRO) in London. did. Distribution of cholera cases and deaths on a map of the region. He observed that most of the cases and deaths were in the Broad Street area, which had received supply from a common water pump, supporting his theory that cholera was a waterborne, infectious disease.
The collection of health data and vital statistics by the GRO has improved over the past decade and a half due to the tireless efforts by another medical doctor, William Farr (1807–1883). Based on data on the time, location and individual distribution of cholera cases and deaths, a map dated 7 September 1854, supplemented by Snow, may have persuaded local authorities in London to remove the handle of the water pump, which They did it reluctantly. The cholera outbreak was brought under control within a few weeks. This marked the beginning of a new era in epidemiology. Jon Snow is often referred to as the father of modern epidemiology and William Farr as the founder of the modern concept of disease surveillance.
a nodal point
In the ensuing years, epidemiology became a major topic for preventing and controlling infectious diseases (and also for non-communicable diseases in the current context). The application of epidemiological principles is made possible through the systematic collection and timely analysis, and dissemination of data on diseases. This is to initiate action to stop or prevent further spread, a process known as disease surveillance.
However, in the late nineteenth century, with the rise of the understanding that microbes cause diseases, and then in the early 20th century, with the discovery of antibiotics and advances in modern medicine, attention was shifted somewhat from epidemiology. Given. High-income countries invested in disease surveillance systems but low- and middle-income countries used limited resources for medical care. Then, in the second half of the twentieth century, as part of global efforts to eradicate smallpox and then tackle a number of emerging and re-emerging diseases, many countries recognized the importance and began to invest in and strengthen disease surveillance systems. Gave. These efforts gained further impetus with the emergence of avian flu in 1997 and the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2002–04.
surveillance in india
A major cholera outbreak in Delhi in 1988 and the Surat plague outbreak of 1994 prompted the Indian government to launch a national surveillance program for communicable diseases in 1997. However, this initiative remained primary in the wake of the SARS outbreak in 2004. India launched the Integrated Disease Surveillance Project (IDSP). The focus under the IDSP was to increase government funding for disease surveillance, strengthen laboratory capacity, train the health workforce, and have at least one trained epidemiologist in every district of India. With this, between 2004 and 2019, almost every passing year, more outbreaks were detected and investigated than in the previous year. It was on the foundation of IDSP (which has now become a full-fledged programme) that when the COVID-19 pandemic struck, India could rapidly deploy teams of epidemiologists and public health experts to respond and guide the response , can coordinate contact tracing. And rapidly increase the testing capacity.
Disease surveillance systems and health data recording and reporting systems are major tools in epidemiology; However, these have performed differently across Indian states, as we now know from the available analyses, be it seroprevalence-survey findings or analysis of additional COVID-19 deaths. According to data from the fourth round of sero-survey, the states of Kerala and Maharashtra can identify one in every six and 12 infections respectively; Whereas in states like Madhya Pradesh, Uttar Pradesh and Bihar, only one out of every 100 COVID-19 infections could be detected, indicating a weak disease surveillance system. The estimated excess deaths are also higher in states with weak disease surveillance systems and citizen registration and vital statistics (CRVS) systems.
In a well-functioning disease surveillance system, any disease increase in cases will be identified very quickly. An example is Kerala, arguably the best performing disease surveillance system among states in India, as it is picking up the maximum number of COVID-19 cases; It may pick up the first case of Nipah virus as early as September 2021. In contrast, cases of dengue, malaria, leptospirosis and scrub typhus were noticed only when more than three dozen deaths and health facilities were reported in several districts of Uttar Pradesh. Began to be amazed. The situation is not much different in states like Madhya Pradesh and Haryana, where viral diseases, most likely dengue, are leading to hospitalizations but not being correctly identified or reported as mystery fever. . It is about 18 months into the COVID-19 pandemic and a lot of political promises to strengthen disease surveillance and health systems, one would have expected to perform better. This raises the question: If the pandemic cannot prompt governments to strengthen disease surveillance systems, what will? Or is it so difficult to strengthen the disease surveillance system?
What should be done
The review of IDSP by Joint Surveillance Mission in 2015 jointly organized by the Ministry of Health and Family Welfare, Government of India and World Health Organization India made some concrete recommendations to strengthen the disease surveillance system. These include increasing financial resource allocation, ensuring adequate numbers of trained human resources, strengthening laboratories, and surveillance of zoonosis, influenza, and vaccine-preventable diseases. Clearly, the time has come to revisit all these recommendations and act on them. At a more specific level, the following should be considered by health policy makers.
First, there is a need to increase the government resources allocated for preventive and promotive health services and disease surveillance by the central and state governments. Second, the workforce in the primary health care system in both rural and urban areas needs to be retrained in disease surveillance and public health functions. There is an urgent need to fill up the vacancies of monitoring staff at all levels. Third, laboratory capacity for COVID-19, developed over the past 18 months, needs to be planned and rebalanced to increase the ability to test for other public health challenges. and infection. This should be combined to create a system in which samples collected are quickly transported and tested and reports are available in real time. Fourth, emerging outbreaks of zoonotic diseases, whether it is Nipah virus in Kerala or avian flu in other states, as well as scrub typhus in Uttar Pradesh, are reminders of the interrelationship of human and animal health. The ‘One Health’ approach has to be promoted beyond policy discourse and work on the ground. Fifth, there will be a special focus on strengthening Citizen Registration and Vital Statistics (CRVS) systems and Medical Certification of Cause of Death (MCCD). These complement the disease surveillance system and often where one is weak, the other is also functioning at sub-optimal. Sixth, this is also the time to develop joint action plans between the state government and municipal corporations and ensure coordinated action to assume responsibility for public health and disease surveillance. Health allocation to corporations by the 15th Finance Commission should be used to activate this process.
check correct pump
The emergence and re-emergence of new and chronic diseases and increase in cases of endemic diseases are partly inevitable. We cannot stop every single outbreak but with a well-functioning disease surveillance system and the application of epidemiological principles, we can reduce their impact. Sometimes, the control of a deadly disease can be as simple as removing the handle of a water pump. Who handles this, however, can only be guided by a disease surveillance system, a civil registration system and coordinated actions between experts in medical statistics, and finally, informed by the application of epidemiological principles. . Indian states need to do everything urgently to detect diseases, which will prepare the country for all future outbreaks, epidemics and pandemics. This is one of the first things that Indian health policy makers should pay attention to.
Dr. Chandrakant Laharia, a physician-epidemiologist, a public policy and health systems expert and co-author of the book, ‘Til We Win: India’s Fight Against the COVID-19 Pandemic’
.