Choose Report Type
Publication Date
Report Upload
Download
(3.75 MB)
What to whats new
vertical
Health & Family Welfare
PDF Text
1
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER 2Vision 2035: Public Health Surveillance in India: A White Paper
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER
Vision 2035: Public Health Surveillance in India
A White Paper
Publishing Agency: NITI Aayog
Year of Publication: 2020
Book, English
ISBN 978-81-949510-6-3
DOI: 10.6084/m9.figshare.14093323
Suggested Citation: Blanchard J; Washington R; Becker M;
Vasanthakumar N; Madangopal K; Sarwal R. et al. Vision 2035: Public
Health Surveillance in India. A White Paper. NITI Aayog. December 2020. 1Vision 2035: Public Health Surveillance in India: A White Paper
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER Vision 2035: Public Health Surveillance in India: A White Paper ii
Foreword ................................................................................................................................................................................
Preface .....................................................................................................................................................................................
Message .................................................................................................................................................................................
Acknowledgements .....................................................................................................................................................
List of Contributors ......................................................................................................................................................
Abbreviations ....................................................................................................................................................................
Executive Summary .....................................................................................................................................................
1. Scope of the Document .................................................................................................................................
2. Vision 2035: Public Health Surveillance in India ..................................................................
2.1 Vision ........................................................................................................................................................................
3. Background and Introduction .................................................................................................................
3.1 Definitions ............................................................................................................................................................
3.2 Progress .................................................................................................................................................................
3.3 Opportunities ....................................................................................................................................................
3.4 Threats .....................................................................................................................................................................
3.5 Challenges in India’s current Public Health Surveillance ........................................
4. Key Considerations in Creating Vision 2035 ..........................................................................
5. The Building Blocks for Vision 2035: Public Health Surveillance in India ....
5.1 Governance: Principle: Develop an eco-system for surveillance ....................
5.2 Information Systems linked with robust lab networks as data sources
for Surveillance .........................................................................................................................................................
5.3 Data Analytics (including Predictive Analytics) ................................................................
5.4 Information for Action: Principle: ‘For Public good’ ..................................................
6. Steps towards achieving Vision 2035: Public Health Surveillance in India .....
6.1 Raise the profile of Public Health Surveillance ................................................................
6.2 Create/Strengthen an Independent Health Informatics Institute ..................
6.3 Define the scope of surveillance into broad categories of diseases/
conditions, keep it simple and strategic ..........................................................................................
6.4 Use a WHO STEPwise approach to include NCD Surveillance .......................
6.5 Prioritise Diseases/Conditions that will be the focus for Surveillance/
Disease Elimination ...............................................................................................................................................
6.6 Improve Core Support Functions, Core Functions and System
Attributes........................................................................................................................................................................
6.7 Streamline data sharing, analysis, dissemination and use for action .........
iv
v
vi
vii
viii
x
xii
1
3
4
5
6
6
8
10
12
17
21
22
23
24
25
27
28
29
29
29
30
30
30
TABLE OF CONTENTS Vision 2035: Public Health Surveillance in India: A White Paper iii
31
31
32
35
37
38
39
40
40
41
22
26
28
33
43
44
45
45
46
47
48
52
53
54
55
49
57
6.8 Encourage Innovations ............................................................................................................................
6.9 Align with Ayushman Bharat .............................................................................................................
6.10 Strengthen laboratory infrastructure, referral networks and
community based surveillance ..................................................................................................................
7. Conclusion ....................................................................................................................................................................
Annexures ............................................................................................................................................................................
1. List of Tables
Table 1: WHO list of Diseases slated for Elimination and their Timelines .......
Table 2: Diseases under Integrated Disease Surveillance Program ......................
Table 3a: The WHO STEPwise approach to NCD surveillance ..................................
Table 3b: STEPS approach to risk factor assessment ..........................................................
Table 4: Criteria for scoring to Prioritise diseases/conditions for
Surveillance ..................................................................................................................................................................
2. List of Figures
Figure 1: The Architecture of Public Health Surveillance in 2035 ...........................
Figure 2: The Proposed Flow of Information for Public Health Surveillance
in 2035 ...............................................................................................................................................................................
Figure 3: The Way Forward: Public Health Surveillance in India ..............................
Figure 4: Integration of PHS into Ayushman Bharat ............................................................
Figure 5: Existing Structure for Public Health Surveillance ...........................................
Figure 6: Improved Health Systems Support, Core Functions & System
Attributes .......................................................................................................................................................................
Figure 7a: Examples of Key Building Blocks for Surveillance ......................................
Figure 7b: Key Building Blocks for Vision 2035: PHS in India .....................................
Figure 8: The Public Health Surveillance Loop ..........................................................................
Figure 9: Framework for Future Detection, Identification and Monitoring
Systems ............................................................................................................................................................................
Figure 10: Real-Time Surveillance of Infectious Diseases in Taiwan .....................
Figure 11: Information Flow - Weekly Surveillance System ..........................................
Figure 12: Linkages of CSU at Central Level ...............................................................................
Figure 13: Conventional IDSP’s Data Collection Process ................................................
Figure 14: New IHIP Real-Time Data Flow Processes .........................................................
3. Background, Scope and Organisation of Disease Surveillance in India ....
4. Bibliography ................................................................................................................................................................ Vision 2035: Public Health Surveillance in India: A White Paper iv
FOREWORD
India has made substantial progress in the prevention, control, and elimination of
major communicable diseases. Smallpox was eradicated worldwide and Polio has been
eliminated in India. India has substantially reduced the incidence of HIV infections by
more than half in the last two decades. Recent outbreaks including the COVID-19 and
Nipah virus have been effectively contained or controlled.
None of these initiatives would have been possible without strong Public Health
Surveillance systems in place. The time is right to enhance the surveillance of non-
communicable diseases and to replace traditional surveillance systems of data-entry with
recent developments in digital health and technology, in alignment with the National
Digital Health Mission. Further, building on the 2017 National Health Policy’s directions
for enhanced surveillance, it is important to enhance citizen-centricity into public health
surveillance and services. As well, the Health and Wellness Centers established under the
Ayushman Bharat provide a platform to enhance community-based surveillance for both
infectious and non-communicable diseases.
The COVID-19 pandemic has provided us with an opportunity to revisit (re) emerging
diseases due to increased interaction between human-animal-environment. Early
identification of this interface is essential to break the chain of transmission and to create
a resilient surveillance system. This vision document on Public Health Surveillance in India
by 2035 is a step in this direction. It articulates the vision and describes building blocks.
It envisions integration, enhanced citizen-centric and community-based surveillance,
strengthened laboratory capacity, expanded referral networks, and a unified Surveillance
Information Platform that will provide data for decision making and action.
I congratulate the NITI Health vertical for bringing out this document, in consultation
with national and global level experts. Vision 2035: Public Health Surveillance in India: A White Paper v
PREFACE
The National Institute for Transforming India (NITI Aayog) functions as a think tank and
resource centre or knowledge hub, fosters cooperative federalism, designs policy and
program framework and guides monitoring and evaluation of National Programs in India.
In alignment with the Universal Health Coverage focus towards achieving the Sustainable
Development Goals by 2030, NITI has focused on holistically transforming the delivery
of health care services across the public and private sectors. Multiple stakeholder
consultations were conducted to identify the priorities for core building blocks of a
Health System for New India.
Enhancing Public Health Surveillance is an important public health function. This includes
the detection of disease and early warning signs of impending outbreaks or epidemics,
both those endemic to the country or those that constitute a public health emergency
of international concern. Tracking acute and chronic disease trends and responding with
timely and effective actions are critical functions of surveillance.
This paper is a vision for Public Health Surveillance in India in 2035, written by national
and global experts in the field of public health surveillance. The document becomes even
more relevant as India and the world tackles the pandemic of COVID-19. The gains made
and lessons learned from COVID-19 and past experience with identifying and controlling
outbreaks, reducing, eliminating and eradicating diseases must be consolidated to
enhance Public Health Surveillance in India. In the spirit of Cooperative Federalism, we
look forward to make this vision a reality and to thus ensure India’s leadership in disease
prevention and response at a global level.
Dr. Vinod. K. Paul,
Member, NITI Aayog vi
MESSAGE
The NITI Aayog was established in 2015 by the Government of India as a policy think
tank. Its aim is to achieve Sustainable Development Goals through cooperative federalism,
fostering the involvement of State Governments and using a bottoms-up approach.
Recently launched initiatives of the Government of India provide an opportunity to re-look
at Public Health Surveillance. The flagship Ayushman Bharat program that is focused on
enhancing the provision of comprehensive primary health care through Health and Wellness
Centres and on reducing catastrophic out-of-pocket expenditure among poor and middle-
class families through the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY)
insurance scheme are opportunities to enhance public health surveillance. The more recent
launch of the Prime Minister’s Atma Nirbhar Swasthya Bharat Yojana (PMASBY) focuses
on making India self-reliant. Under this program, plans are afoot to enhance laboratory
infrastructure and health systems at the block level in order to prepare and respond in a
timely manner to future pandemics.
Surveillance is ‘Information for Action’. Public health surveillance, an important public
health function, cuts across primary, secondary and tertiary levels of health care. Beyond
improving existing isolated systems, the integrated solution envisioned in this document
encompasses a ‘One-Health’ approach that amalgamates health information from different
sources including human, plant and animal surveillance. A unitised and unified real-time
surveillance that is not based on traditional systems of data entry and upload, but one that
allows interoperability and data sharing mechanisms, capitalising on technological and
digital advances are in alignment with the National Digital Health Mission.
The vision suggests the utilisation of new situation-aware real-time signals from social media,
mobile/sensor networks and citizens’ participatory surveillance systems for event based
epidemic intelligence in addition to the existing systems and electronic health records
for case-based surveillance linked through the optimal use of unique health identifier.
Finally, the vision highlights the effective support coordination of multidisciplinary teams,
risk communication with citizens as the primary stakeholders and the implementation of
prevention measures at all levels for a timely and effective public health response. We
must not lose the opportunity that the COVID-19 pandemic has provided us. We must
strengthen our health systems and services and public health surveillance mechanisms.
The vision document provides insights and ideas for India to move ahead in this direction.
Amitabh Kant,
Chief Executive Officer, NITI Aayog
Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper Traditional public health disease surveillance systems in India have remained fragmented,
siloed, and limited to few diseases. As India re-imagines and reforms its health systems,
we need to ensure that our Public Health Surveillance systems are also made citizen-
centric and within the context of the overall socio-economic development of the country.
In 2020, the NITI Aayog signed a Letter of Agreement with the University of Manitoba,
Winnipeg, Canada to develop a white paper on a Vision for Public Health Surveillance in
India by 2035.
This vision document on Public Health Surveillance in India-2035, which takes forward the
vision as envisaged in the National Health Policy 2017, lays the foundation for integrated
surveillance of both communicable and non-communicable diseases.
This document identifies four building blocks for this vision. These include a) an
interdependent federated system of Governance architecture between the Centre and
States; b) new data collection and sharing mechanisms for surveillance based on unitized,
citizen-centric comprehensive Electronic Health Records with a unique health identifier,
amalgamating existing disease surveillance programs, complemented by information
from periodic surveys; c) enhanced use of new data analytics, data science, artificial
intelligence and machine learning; and d) advanced health informatics.
We hope that this document will pave the road towards collectively propelling India to
be a regional and global leader with ‘Information for Action’, in consideration of the
overarching principle ‘for the public good’.
We thank the Institute of Global Public Health at the University of Manitoba and the
national and global experts who have compiled this vision document. We would like
to acknowledge the various contributors listed for their unstinted commitment and
dedication to this exercise.
We are grateful to Dr. Rajiv Kumar, Vice Chairman, Dr. Vinod K Paul, Member, and
Shri Amitabh Kant, CEO NITI Aayog, for their constant inspiration and guidance that made
this document possible, and the health division team Shri Alok Kumar, Former Advisor,
and Dr. K Madan Gopal, Senior Consultant for having contributed to this exercise.
Dr. Rakesh Sarwal
Additional Secretary, NITI Aayog
Vision 2035: Public Health Surveillance in India: A White Paper
ACKNOWLEDGEMENTS
vii Vision 2035: Public Health Surveillance in India: A White Paper LIST OF CONTRIBUTORS
No.
1
2
3
4
5
6
7
8
9
1
2
3
4
Professor/Director
Associate Professor
Associate Professor
Executive Director: Uttar Pradesh
Technical Support Unit (UPTSU)
Assistant Professor
Director: UPTSU
Program Specialist
Director: UPTSU
Deputy Director: UPTSU
Additional Secretary
Former Advisor
Principal Secretary Health
Senior Consultant (Health)
Officer on Special Duty (OSD)
University of Manitoba/Institute
of Global Public Health
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
NITI Aayog
NITI Aayog
Government of Uttar Pradesh
NITI Aayog
NITI Aayog
NameDesignationOrganization
Vision 2035: Public Health Surveillance in India: A White Paper
James Blanchard
Reynold Washington
Marissa Becker
Vasanthakumar N
Shajy Isac
Sameer Kanwar
Antony Joseph
Bidyut Sarkar
Sushant Jain
Rakesh Sarwal
Alok Kumar
K Madan Gopal
K Venkatanarayan
AUTHORS
NITI AAYOG
viii Vision 2035: Public Health Surveillance in India: A White Paper 1
2
3
4
5
6
7
8
,
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Gangakhedkar R
Himanshu Chauhan
Kamlesh Sarkar
Kayla Laserson
Manoj V Muhrekar
M. K. Sudarshan
Nivedita Gupta
Pavana Murthy
Priya Abraham
Rajeev Sadanandan
Rajesh Bhatia
Rosanna Peeling
Samiran Panda
Sanjay Mehendale
Sanjay Sarin
Sanjay Tyagi
Sanket Vasant
Kulkarni
Shanta Dutta
Sujeet Kumar Singh
Suman Sharma
Suresh Mohammed
Swasticharan L
Tripurari Kumar
Head, Epidemiology &
Communicable Diseases
Joint Director & In-charge
IDSP
Director
Deputy Director,
Infectious Diseases
Director
Professor & Head
Scientist F, Epidemiology &
Communicable Diseases
Infectious Diseases
Surveillance
Director
Chief Executive Officer
Former Director,
Communicable Diseases
Professor and Chair,
Diagnostics Research
Director
Former Director, NIE
Former Director, ICMR
Country Director
Director General
Deputy Director
Director
Director
Senior Health Specialist
Chief Medical Officer
Epidemiologist & EIS
Officer-India
Indian Council for Medical Research (ICMR),
New Delhi
National Centre for Diseases Control (NCDC),
New Delhi
National Institute of Occupational Health,
Ahmedabad
India Country Office; Bill & Melinda Gates
Foundation, New Delhi
National Institute of Epidemiology, Chennai
Rajiv Gandhi Institute of Public Health,
RGUHS, Bengaluru
Indian Council of Medical Research (ICMR),
New Delhi
World Health Organization (WHO), New Delhi
National Institute of Virology, Pune
Health Systems Transformation Platform
(HSTP), New Delhi
World Health Organization (WHO)
South East Asia Regional Office (SEARO),
New Delhi
London School of Hygiene and Tropical
Medicine (LSHTM), England
National AIDS Research Institute, Pune
National Institute of Epidemiology, Chennai,
Indian Council of Medical Research, New Delhi
Foundation for Innovative New Diagnostics
(FIND), New Delhi
Directorate General of Health Services (DGHS),
New Delhi
National Centre for Disease Control, New Delhi
National Institute for Cholera and Enteric
Diseases (NICED), Kolkata
National Centre for Disease Control, New Delhi
Individual Capacity
World Bank, New Delhi
Director General of Health Services, New Delhi
South Delhi Municipal Corporation, New Delhi
No.NameDesignationOrganization
EXPERTS WHO CONTRIBUTED
Vision 2035: Public Health Surveillance in India: A White Paperix Vision 2035: Public Health Surveillance in India: A White Paper ABBREVIATIONS
AES
AFI
AFP
AIDS
AMR
API
API
CBHI
CDC
CHC
CRS
CSU
CTD
DGHS
DH
DHF/DSS
DIM
DSO
DSU
EDL
EHR/EMR
EMS
ESIC
GoI
GHSA
HIV
HR
HSS
HWC
IBBS
IBD
ICMR
IDSP
IDSR
IHIP
IoT
JE
Acute Encephalitis Syndrome
Acute Febrile Illness
Acute Flaccid Paralysis
Acquired Immunodeficiency Syndrome
Anti-microbial Resistance
Application Programming Interface
Annual Parasite Index
Central Bureau of Health Intelligence
Centre for Disease Control
Community Health Centre
Congenital Rubella Syndrome
Central Surveillance Unit
Central TB Division
Directorate General of Health Services
District Hospital
Dengue Haemorrhagic Fever, Dengue Shock Syndrome
Detection, Identification, Monitoring
District Surveillance Officer
District Surveillance Unit
Essential Diagnostics List
Electronic Health Record/Electronic Medical Record
Emergency Management System
Employees State Insurance Corporation
Government of India
Global Health Security Agenda
Human Immunodeficiency Virus
Human Resources
HIV Sentinel Surveillance
Health and Wellness Centre
Integrated Behavioural and Biological Surveillance
Invasive Bacterial Diseases
Indian Council for Medical Research
Integrated Disease Surveillance Program
Integrated Disease Surveillance and Response
Integrated Health Information Platform
Internet of Things
Japanese Encephalitis
Vision 2035: Public Health Surveillance in India: A White Paperx Vision 2035: Public Health Surveillance in India: A White Paper MC
MDR-TB
MNCH
MPH-EIS
NAAC
NACO
NAP
NARI
NCD
NCDC
NEDL
NFHS
NHM
NICD
NICED
NIOH
NITI Aayog
NTEP
NVBDCP
OTP
PHC
PHS
PMJAY
PoC
PROMED
RCH
RNTCP
SARS
SEED
SSO
SSU
STI
TB
UHID
VRDL
WHO
Medical College
Multi-drug resistant TB
Maternal, Newborn and Child Health
Masters in Public Health, Epidemic Intelligence Service
National Apical Advisory Committee
National AIDS Control Organisation
National Action Plan
National AIDS Research Institute
Non-communicable Diseases
National Centre for Disease Control
National Essential Drugs List
National Family Health Survey
National Health Mission
National Institute of Communicable Diseases
National Institute for Cholera and Enteric Diseases
National Institute for Occupational Health
National Institute for Transforming India
National TB Elimination Program
National Vector Borne Disease Control Program
One-time password
Primary Health Centre
Public Health Surveillance
Pradhan Mantri Jan Arogya Yojana
Point-of-Care
Program for Monitoring Emerging Diseases
Reproductive and Child Health
Revised National TB Control Program
Severe Acute Respiratory Syndrome
System for Early Warning Based on Emergency Data
State Surveillance Officer
State Surveillance Unit
Sexually Transmitted Infection
Tuberculosis
Unique Health Identifier
Viral Research and Diagnostic Laboratories
World Health Organization
Vision 2035: Public Health Surveillance in India: A White Paperxi Vision 2035: Public Health Surveillance in India: A White Paper EXECUTIVE SUMMARY
Vision 2035: Public Health Surveillance in India
NITI Aayog’s mandate is to provide strategic directions to the various sectors of the
Indian economy. In line with this mandate, the Health Vertical released a set of four
working papers compiled in a volume entitled ‘Health Systems for New India: Building
Blocks – Potential Pathways to Reform’ during November 2019.
“India’s Public Health Surveillance by 2035” is a continuation of the work on Health
Systems Strengthening. It contributes by suggesting mainstreaming of surveillance by
making individual electronic health records the basis for surveillance.
Public Health Surveillance (PHS) cuts across primary, secondary, and tertiary levels of care.
Surveillance is an important Public Health function. It is an essential action for disease
detection, prevention, and control. Surveillance is ‘Information for Action’.
This paper is a joint effort of the Health vertical, NITI Aayog, and the Institute for Global
Public Health, University of Manitoba, Canada, with contributions from technical experts
from the Government of India, States, and International agencies.
In 2035,
• India’s Public Health Surveillance will be a predictive, responsive, integrated, and tiered
system of disease and health surveillance that is inclusive of Prioritised, emerging, and
re-emerging communicable and non-communicable diseases and conditions.
• Surveillance will be primarily based on de-identified (anonymised) individual-level patient
information that emanates from health care facilities, laboratories, and other sources.
• Public Health Surveillance will be governed by an adequately resourced effective
administrative and technical structure and will ensure that it serves the public good.
• India will provide regional and global leadership in managing events that constitute a
Public Health Emergency of International Concern.
Multiple disease outbreaks have prompted India to proactively respond with prevention
and control measures. These actions are based on information from public health
surveillance. India was able to achieve many successes in the past. Smallpox was eradicated
and polio was eliminated. India has been able to reduce HIV incidence and deaths and
advance and accelerate TB elimination efforts. Many outbreaks of vector-borne diseases,
acute encephalitis syndromes, acute febrile illnesses, diarrhoeal and respiratory diseases
have been promptly detected, identified and managed. These successes are a result
of effective community-based, facility-based, and health system-based surveillance. The
program response involved multiple sectors, including public and private health care
systems and civil society.
Vision 2035: Public Health Surveillance in India: A White Paperxii Vision 2035: Public Health Surveillance in India: A White Paper The COVID-19 pandemic has further challenged the country. India rapidly ramped up
its diagnostic capabilities and aligned its digital technology expertise. This ensured that
there was a comprehensive tracking of the pandemic. As well, relevant information was
widely shared with the public. India rapidly instituted both case-based (Trace, Test, Treat)
and population-based measures (wear masks, wash hands, maintain distance, avoid
crowding and closed spaces) for COVID-19 prevention, management, containment, and
control. This vision document describes what India’s Public Health Surveillance can be in
2035.
This vision document on India’s Public Health Surveillance by 2035 builds on opportunities
that include the Ayushman Bharat scheme that establishes health and wellness centers
at the community level- to strengthen non-communicable disease prevention, detection,
and control and assures government payment for hospitalisation- to reduce out-of-pocket
expenses of individuals and families at the bottom of the pyramid.
• It builds on initiatives such as the IHIP of the Integrated Disease Surveillance Program.
• It aligns with the citizen-centricity highlighted in the National Health Policy 2017 and
the National Digital Health Blueprint. It encourages the use of mobile and digital
platforms and Point-of-Care devices and diagnostics for amalgamation of data capture
and analyses.
• It highlights the importance of capitalizing on initiatives such as the Clinical
Establishments Act to enhance private sector involvement in surveillance.
• It points out the importance of a cohesive and coordinated effort of apex institutions
including the National Centre for Disease Control, the Indian Council of Medical
Research, and others. As well, there may be a need to create an independent Institute
of Health Informatics.
The document identifies gap areas in India’s Public Health Surveillance that could be
addressed.
• India can create a skilled and strong health workforce dedicated to surveillance activities.
• Non-communicable disease, reproductive and child health, occupational and
environmental health and injury could be integrated into public health surveillance.
• Morbidity data from health information systems could be merged with mortality data
from vital statistics registration.
• An amalgamation of plant, animal, and environmental surveillance in a One-Health
approach that also includes surveillance for anti-microbial resistance and predictive
capability for pandemics is an element suggested within this vision document.
• Public Health Surveillance could be integrated within India’s three-tiered health system.
• Citizen-centric and community-based surveillance, and use of Point-of-Care devices
and self-care diagnostics could be enhanced.
• Laboratory capacity could be strengthened with new diagnostic technologies including
molecular diagnostics, genotyping and phenotyping. To establish linkages across the
three-tiered health system, referral networks could be expanded for diagnoses and
care.
Vision 2035: Public Health Surveillance in India: A White Paperxiii Vision 2035: Public Health Surveillance in India: A White Paper xiv
1. Establish a governance framework that is inclusive of political, policy, technical, and
managerial leadership at the national and state level.
2. Identify broad disease categories that will be included under Public Health Surveillance.
3. Enhance surveillance of non-communicable diseases and conditions in a step-wise
manner.
4. Prioritise diseases that can be targeted for elimination as a public health problem, on
a regular basis.
5. Improve core support functions, core functions, and system attributes for surveillance
at all levels - national, state, district, and block.
6. Establish mechanisms to streamline data sharing, capture, analysis, and dissemination
for action. These could include the use of situation-aware real-time signals from social
media, mobile sensor networks and participatory surveillance systems for event-
based epidemic intelligence.
7. Encourage innovations at every step in surveillance activity.
All through this process, consider strengthening human resource capacity, laboratory
infrastructure, referral networks, and community-based surveillance. Implementation of
this vision can thrust India to be a global/regional leader in Public Health Surveillance -
‘Information for Action’.
Four building blocks are envisaged for this vision:
1. An interdependent federated system of Governance Architecture between the Centre
and States
2. Enhanced use of new data collection and sharing mechanisms for surveillance based on
unitized, citizen-centric comprehensive Electronic Health Records (EHR) with a unique
health identifier (UHID). As well, existing disease surveillance data and information
from periodic surveys will complement this information
3. Enhanced use of new data analytics, data science, artificial intelligence, and machine
learning, and
4. Advanced health informatics.
Going forward, India’s Public Health Surveillance will be based on individual EHR that
capture and amalgamate individuals’ health-care related information through the use
of a UHID. This is used in every clinical, laboratory or pharmacy visit and for vertical
disease control programs. Periodic surveys are positioned as additional complementary
methods to reassess the incidence and prevalence of diseases/risk factors, to adjust and
refine standard case definitions periodically, to define epidemic thresholds, and to refine
response levels and measures. A Surveillance Information Platform will store, analyse, and
auto-generate relevant reports for action. As well, this remains a repository for further
analysis and research, which will complement the available surveillance information.
Drawing on best practices from India and other developing and developed country
experiences, the document suggests next steps for India to move forward towards this
vision. All these steps are in alignment with the principle to raise the profile of surveillance
as a tool for the public good. The steps are suggested as a continuous cycle rather than
a sequential process. Vision 2035: Public Health Surveillance in India: A White Paper SCOPE OF THE DOCUMENT1
Vision 2035: Public Health Surveillance in India: A White Paper1 Vision 2035: Public Health Surveillance in India: A White Paper 2
SCOPE OF THE DOCUMENT
This is a vision document for Public Health Surveillance in India in 2035. The document
defines the vision, illustrates the architecture, describes the proposed flow of information,
lists key questions and considerations that are necessary to expand the scope of Public
Health Surveillance in India, defines the four building blocks and lists possible steps
towards achieving the vision.
The vision document briefly describes the progress made by India in Public Health
Disease Surveillance and builds on the existing experience of public health surveillance
systems with a focus on governance that is based on cooperative federalism, fostering
the involvement of state governments and using a bottoms-up approach. It aligns with
inclusive and sustainable growth and the principles stated in the National Health Policy 2017.
These include human resources that practice professionalism, integrity and ethics, and
public health services that reduce inequity and catastrophic costs for health care. The
focus is on Universal Health Coverage and patient-centred quality of care that is gender
sensitive, effective, safe, convenient and provided with dignity and confidentiality. The
multi-stakeholder approach with partnership and participation of all non-health ministries,
communities, academic institutions, not-for-profit agencies and the health care industry;
pluralism to optimise services wherever patients first seek care; decentralisation of
decision making; citizen centricity; and focus on expansion of Public Health Surveillance
to include non-communicable and occupational diseases, including mental health, are all
touched upon.
In addition to building on India’s past experience, the document draws on lessons
learned from global best practices including examples from Thailand, Taiwan, Germany,
the United Kingdom, the United States of America and Canada.
The document does not include funding and budget requirements. The analysis of
the capacity of existing institutions is only based on reviews of evaluation reports. The
document excludes a focus on COVID-19, even though India’s capacity and resilience
have been challenged by this pandemic. Instead, the document focuses on expanding
surveillance to be inclusive of non-communicable diseases, occupational, injury and
environmental conditions in a One-Health approach for Public Health Surveillance.
Next steps include the creation of a road-map or blueprint for action. As well, it would
be important to set up effective and responsive governance mechanisms that establish
political, technical, digital and managerial leadership in order to enable India reach this
vision by 2035. Vision 2035: Public Health Surveillance in India: A White Paper VISION 2035:
Public Health Surveillance
in India
2
Vision 2035: Public Health Surveillance in India: A White Paper3 Vision 2035: Public Health Surveillance in India: A White Paper VISION 2035: Public Health Surveillance in
India
Surveillance is defined as “a core public health function that ensures that the right
information is available at the right time and in the right place in order to inform public
health decisions and actions”
1
. In short, surveillance should be “Information for Action”
2,3
.
In 2035, India’s Public Health Surveillance will:
Vision
*Ability to predict a disease event or outbreak
π
Ability to respond positively with speed and sensitivity
#
Implies integration between centre, state and district, as well as between public and private health sectors
@
Refers to the 3 tier health care delivery system in India; primary care at Health and Wellness centres, sub-centres and primary health care centres,
secondary care at first level referral units and district hospitals (few specialities – medicine, obstetrics & gynaecology, paediatrics and emergency
care), and tertiary care at medical colleges and apex institutions (all specialists and super-specialists, equipped with high level laboratories for
advanced diagnostics and specialist procedures).
$
Prioritisation is a periodic exercise, repeated every 3-5 years, based on specific objective criteria, described later within this document.
^Includes clients/patients, governments, academia, industry, media and non-government organisations.
01
02
04
05
03
Be a predictive*, responsive
π
, integrated
#
and tiered
@
system of disease and
health surveillance that is inclusive of Prioritised
$
, emerging and re-emerging
communicable and non-communicable diseases and conditions. Readiness for
actions at community, facility and health and governance systems are key aspects
of the response.
Be a system that is primarily based on de-identified individual level patient
information which includes health care facility and laboratory data as key sources,
amongst others.
Serve public good through the provision of meaningful ‘Information for Action’
to relevant stakeholders^, with due attention to privacy and confidentiality of the
individual, and enabled with a client feedback mechanism.
Provide regional/global leadership in compliance with International Health
Regulations and management of events that constitute a Public Health Emergency
of International Concern
Be governed by an effective administrative and technical structure that is adequately
resourced.
1
Department of Health, PHE Transition Team. Towards a Public Health Surveillance Strategy for England.2012
2
Dworkin M S. Surveillance of Infectious Diseases Is Information for Action. AMA Journal of Medical Ethics. Virtual Mentor.2006;8(4):223-226.
DOI:10.1001/virtualmentor.2006.8.4.cprl1-0604.
3
World Health Organization. STEPS: A Framework for Surveillance. The WHO STEPwise Approach to Surveillance of Noncommunicable
Diseases (STEPS) Geneva, Switzerland.2003.
4 Vision 2035: Public Health Surveillance in India: A White Paper
BACKGROUND
AND INTRODUCTION
3
5 6Vision 2035: Public Health Surveillance in India: A White Paper
4
https://www.etymonline.com/word/surveillance and https://www.merriam-webster.com/dictionary/surveillance
5
Langmuir A D. The surveillance of communicable diseases of national importance. The New England Journal of Medicine.1963
DOI:10.1056/NEJM196301242680405
6
World Health Organization. Report of the Technical Discussions at the 21st World Health Assembly on National and Global Surveillance
of Communicable Disease. Geneva, Switzerland.1968
3.1 Definitions
The focus was towards ‘action’ that results from a system of surveillance. In this document,
we propose to use the definition ‘Surveillance is Information for Action’, drafted by an
expert group in 2012 by the Department of Health - Public Health Surveillance in the
vision document entitled, “Towards a Public Health Surveillance for England”.
3.2 Progress made thus far for Public Health Surveillance (PHS) in
India
The 1988 Cholera outbreak in Delhi and 1994 plague outbreak in Surat prompted the
Government of India (GoI) to constitute a National Apical Advisory Committee (NAAC)
in 1995. In 1997, the National Surveillance Program for Communicable Diseases was
launched. HIV Sentinel Surveillance (HSS) was perhaps one of the first nation-wide disease
surveillance programs which began in 1992 and was scaled up country-wide a decade
later.
The World Bank funded the GoI in 2004 for a ten year ‘Integrated Disease Surveillance
Project – IDSP’. This was later converted into a program and funded under the 12th plan
(2012-17) within the National Health Mission. The Central Surveillance Unit of the IDSP is
housed in the National Centre for Disease Control (NCDC), New Delhi.
The Indian Council of Medical Research (ICMR) has played a key role in strengthening
surveillance and research related to surveillance. The network of ICMR continues to
expand and at present has 106 Viral Research and Diagnostic Laboratories (VRDL), 35
diagnostic centres and a number of apex institutions. Together, these institutions have
played key roles in the identification of existing and new pathogens and their variants,
in controlling newly emerging infections (SARS, Nipah virus) and in estimating disease
burden using mathematical modelling for diseases like malaria and dengue fever.
The French defined surveillance in three words, ‘to watch over’
4
.
Langmuir defined surveillance as ‘the continued watchfulness over distribution
and trends of incidence through systematic collection, consolidation, and
evaluation of morbidity and mortality reports and other relevant data”
5
.
The Centre for Disease Control, Atlanta, US defined surveillance as ‘the
ongoing systematic collection, collation, analysis and interpretation of data
and dissemination of information to those who need it, in order that action
is taken.”
6
1963
20
years
later
1968 77Vision 2035: Public Health Surveillance in India: A White Paper
In 2019, the World Health Organization (WHO) in partnership with the GoI launched
the Integrated Health Information Platform (IHIP) within the IDSP program. The IHIP is
a digital web-based open platform that captures individualised data in almost real-time,
generates weekly and monthly reports of epidemic outbreaks and early warning signs
and captures response by ‘rapid response teams’, for 33+ disease conditions.
Other data sources capture information on diseases of national importance such as TB.
TB was made a notifiable disease in 2012 and the Nikshay platform serves as a source
of data to estimate burden and to track disease trends and outcomes. In late 2019, the
pandemic of COVID-19 has given further impetus to strengthen PHS in India.
Over the years, these various institutions, networks and programs have been fairly
effective. Small pox was eradicated in India in 1979, a year before its global eradication.
India was declared ‘Polio free’ in 2014, three years after the last case detection in India
in 2011. Epidemics of SARS, Nipah and rotavirus have been rapidly detected through
the efficient viral research and diagnostic laboratory network of ICMR, and have been
effectively controlled.
The ICMR network is playing a critical role in the containment of the COVID-19 pandemic.
The pandemic has catalysed the GoI’s laboratory infrastructure and health information
network for surveillance truly epitomising ‘Information for Action’. Vision 2035: Public Health Surveillance in India: A White Paper 3.3 Opportunities
There are important and timely opportunities within the Indian and global context that
can be leveraged to expand a Public Health Surveillance system in India.
There has been an explosion of digital technologies in health. NITI Aayog launched
the National Digital Health Blueprint in July 2019. Two key recommendations
from the National Digital Health Blueprint document are the use of a unique
health identity number (UHID) and the strengthening of electronic health records
in the public and private health care sectors. These two recommendations are
central to the basis for the future of surveillance in India, as outlined in this vision
document.
03
01
India recently rolled out the Ayushman Bharat scheme. One of the two inter-
related key features of this scheme is the expansion of primary health care
initiatives through the creation of 150000 Health and Wellness Centres (HWCs),
staffed by front-line workers and a new cadre of Community Health Officers.
The second is the Pradhan Mantri Jan Arogya Yojana (PMJAY). PMJAY is the
largest health assurance scheme in the world which aims to provide a health
cover of Rupees five lakhs per family per year for secondary and tertiary care
hospitalisation for poor and vulnerable families that form the bottom 40% of the
Indian population. The HWCs present an opportunity to conduct surveillance for
infectious disease, non-communicable disease, occupational health and injury
related conditions at the individual, family and primary care level. The PMJAY
could be a useful source of information to estimate out-of-pocket expenditure
on hospitalisation expenses, as well as for surveillance of diseases managed
within in-patient facilities.
02
The Integrated Health Information Platform (IHIP) under the IDSP is already
partially functional across several states. The experience in few states has
demonstrated its potential to detect epidemics, issue early warning signals,
capture outbreak investigation and respond appropriately. There is potential
for this platform to be rapidly scaled up across the country, to expand on the
number and type of disease conditions captured and to include data from the
private sector. However, surveillance cannot be seen as a separate activity from
patient care. This document emphasizes that surveillance can ride on top of a
unitized, citizen centric electronic health record (EHR).
Vision 2035: Public Health Surveillance in India: A White Paper8 9Vision 2035: Public Health Surveillance in India: A White Paper
The growth of smart phones and penetration of mobile telephones also presents
a huge opportunity for the paperless capture of almost real-time information,
inclusive of geo-coordinates. Additionally, the dissemination of meaningful
information to relevant stakeholders is feasible using smart-apps, a health portal
and to link to call centres that function as helplines and for other emerging
purposes.
04
Legal frameworks for health care and surveillance already exist within the
country. The Clinical Establishments Act (Registration and Regulation), 2010
has been passed and a number of states have been able to create directories
of clinical establishments and use this information to build upon and enhance
notification for disease, death and births, especially within the private sector.
Similarly, nationwide digitisation of the Health Management Information System
can enable timely and appropriate human resource recruitment and deployment,
especially of specialist services, including microbiologists and pathologists at the
block/district level.
Point-of-Care (PoC) diagnostics and screening tests, including gene testing for
infectious diseases and non-communicable diseases are rapidly developing. The
rapid development of PoC tests and hand-held devices will enable reaching
populations that are otherwise unreached by the health system and can facilitate
timely diagnoses and enable self-diagnosis as well.
Finally, institutions, including the ICMR and its apex institutions, the NCDC, and
the Centre and State governments, have demonstrated strong ability to rapidly
respond in order to contain, control and coordinate responses to ‘Public Health
Emergencies of International Concern’.
05
06
07
Vision 2035: Public Health Surveillance in India: A White Paper9 03
Anti-microbial Resistance – a growing threat: A third but important threat
that is emerging is the growing prevalence and complexity of Anti-microbial
Resistance (AMR). A decade after New Delhi lent its name, unwillingly, to
a dreaded super-bug gene, bla-NDM-1, the antibiotic resistant gene was
Vision 2035: Public Health Surveillance in India: A White Paper
3.4 Threats
01
02
Re-emerging and new Communicable Diseases: A number of new infections
have emerged and pathogens and diseases have re-emerged with resistant
or mutant strains. 75% of emerging/re-emerging diseases are zoonotic and
therefore a system of active animal surveillance and integration with agriculture
and other sectors is critical. Travel, trade and migration are growing and people’s
exposure to more exotic food, exotic animals and travelling to exotic locations
is increasing. There is increasing and more rapidly forming drug resistance
and there are syndemics of diseases which may either both be infectious as in
the case of HIV and TB, or in combinations where one is infectious while the
other is not, as in the case of TB and diabetes. Either way, these syndemics
adversely influence disease outcomes. Surveillance activities may consider these
interactions. Finally, the role of social, structural and biological determinants
of disease and death are rarely completely understood in terms of disease
distribution or prevalence.
Increasing rates of non-communicable diseases and acute and chronic
conditions: The Ministry of Health in its document “India – Health of Nation’s
States” (2019) states that 61% of mortality and 55% of the disability adjusted
life years were caused by NCD in 2016. NCD are not a single entity and
include cancers, cardiovascular conditions, respiratory diseases, diabetes,
and hypertension. Palliative care, mental health, emergency care related
to trauma, accidents, suicides and homicide are growing concerns as is
gender-based violence, abuse of children, accidents and occupational injury. The
elderly and adolescent are periods of life with increasing importance for public
health interventions, including surveillance, as both age groups tend to be very
vulnerable to disease, including accidents, abuse and injury. NCD surveillance
is often focused only on the surveillance of risk factors. The risk factors for
NCD are often multiple and are related to social behaviours including lifestyle,
food, exercise, stress and behavioural or addictive behaviours relating to drugs,
alcohol and tobacco, and environmental pollution. There is often a significant
time-lag between exposure and disease and this varies for different disease
conditions. Very often the ability to stage or capture this type of information
from hospital records or cancer registries is a challenge because of the lack of
standardisation and inadequate attention that is given to documentation.
10 11Vision 2035: Public Health Surveillance in India: A White Paper
7
Ranjalkar J, Chandy SJ. India’s National Action Plan for antimicrobial resistance - An overview of the context, status, and way ahead. J
Family Med Prim Care. 2019;8(6):1828-1834. DOI:10.4103/jfmpc.jfmpc_275_19
discovered in one of the pristine outposts on the planet—the Arctic. Between
2008, when the gene was first detected in a Swedish patient of Indian origin,
who had travelled to India that year, and 2019 when it was traced in Arctic, the
gene has been found in over 100 countries, and with new variants, confirming
the rapid spread of anti-microbial resistance, and showing what a big mistake
it would be to view this global challenge only through local lens. Factors
which contribute to AMR include overuse and misuse of antibiotics through
self-medication, indiscriminate access to antibiotics without prescription and
the use of pharmacies and informal healthcare providers as basic sources for
healthcare seeking, and the lack of knowledge about when to use antibiotics.
The addition of antibiotics to agricultural feed, also promotes drug resistance.
Veterinary use in livestock and poultry contributes to the problem of AMR.
Additionally, effluents discharged from pharmaceutical manufacturing units
also contribute to AMR development. In the face of growing ineffectiveness of
existing antibiotics, and absence of new discoveries of superior next generation
antibiotics, the world is heading to a public health emergency on AMR. It is
widely known that India bears a very high burden of AMR but in the absence of
detailed data, it is difficult to accurately estimate the size of the burden. AMR
has been recognized as one of the top priority focus areas of the WHO, which
has called for convergence between stakeholders and adoption of a “One-
Health” approach in tackling this challenge.
The Ministry of Health and Family Welfare launched the National Action Plan
on AMR (NAP-AMR) in April 2017, which highlights the need to tackle AMR
across multiple sectors such as human health, animal husbandry, industry and
environment in line with the “One-Health” approach
7
. However, at the state
level only a few states have released their State Action Plan for Containment of
Antimicrobial Resistance.
In India, the data on AMR that is being collated and archived appears to be too
little and too patchy to be fully representative to make meaningful assessment
and intervention. The ICMR collects AMR data from 25 public and private
hospitals and laboratories and while this is an important part, there is an urgent
need to expand on this for a country as vast and diverse as India. To better
understand and respond to antimicrobial resistance patterns and key drivers,
information about AMR incidence, prevalence, and trends may be gathered
as part of country’s disease surveillance mechanism. Stronger networks of
information sharing, and alignment with the global strategic research agenda
would help improve our understanding of the local, national and global AMR
patterns, burden and trends.
Vision 2035: Public Health Surveillance in India: A White Paper11 12Vision 2035: Public Health Surveillance in India: A White Paper
3.5 Challenges in India’s existing Public Health Surveillance
Despite significant progress and potential for an expanded and enhanced Public Health
Surveillance system in India, there are a number of challenges that need to be addressed
in the short term:
Implementation challenges – patchy surveillance, not comprehensive:
The IHIP is not yet fully operational across the country. There are a number of
notable implementation challenges. One of the important system design issues is
that data on the citizen utilisation of services for treatment of disease is separate
from notification mechanisms for disease outbreaks. There is a lack of uniformity
in outbreak investigation and reporting and there are limitations in geographic
coverage within states. HIV Sentinel Surveillance is a “program” activity, limited
in scope to two government facilities within a district. TB notification still misses
a modest proportion of estimated cases annually. There have been many pilot
projects implemented to enhance the existing surveillance system, including
influenza surveillance supported by the WHO, a CDC pilot to strengthen labs
and referral networks for Acute Encephalitis Syndrome (AES) and Acute Febrile
Illnesses (AFI). These remain as ‘research driven’ pilots, with limited resources and
willingness by governments to scale these up.
India needs to address these implementation challenges, cognisant of the fact
that relevant data on diagnosis and treatment provided to citizens across the
public and private sector may be captured for effective surveillance. Additionally,
a mechanism to transition, scale up and sustain pilot/innovative models for
surveillance is urgently needed.
Surveillance functions in vertical siloes of programs and institutions: Vertical
programs such as the National AIDS Control Program and the National TB
Elimination Program have achieved significant success in reducing disease
transmission, increasing the proportion of people who know their HIV or TB
status, enhancing the coverage of treatment among those infected or confirmed
with disease and reducing mortality from the disease. The Reproductive and Child
Health (RCH) program portal is able to track coverage of pregnant women for
antenatal care, institutional delivery and for maternal and child health outcomes.
However, surveillance data from these vertical programs are not yet fully integrated
within a single unified surveillance platform. Additionally, “Research” or the use
of existing data systems to answer important programmatic/policy questions has
been limited. Systematic quality control under surveillance was never optimally
addressed. There is limited ability of program implementation structures to work
in synchrony with research organizations and vice versa.
For example: Currently, similar data is collected by three organisations (IDSP,
ICMR’s Virology Diagnostic Research Laboratory Network and the National Vector
Borne Disease Control Program (NVBDCP) surveillance network), and there is
01
02 13Vision 2035: Public Health Surveillance in India: A White Paper
Private sector involvement in surveillance is limited:
The private sector is not a homogenous entity; it includes unregistered practitioners,
stand-alone clinics, pharmacies and laboratories, smaller nursing homes, medium
to large hospitals, medical colleges, corporate institutions and apex institutions.
Additionally, there are mission hospitals and independent trusts that run health
care facilities, which are not-for-profit institutions that are also included within the
private sector. Private sector participation in disease surveillance is minimal.
There are a number of questions that need to be explored before the private
sector is involved in Public Health Surveillance. For which disease conditions could
private sector be involved in surveillance? At what levels of care could private
sector be involved in Public Health Surveillance? How does one ensure consistency
and quality of a private sector site in surveillance, which is an on-going activity?
Under what circumstances and for which diseases could data from private sector
insurance be utilised for surveillance purposes?
A citizen centric EHR process where the citizen gets the advantage of his health
record from birth to death getting updated both from the public and private sector
will aid quality real time surveillance and ensure full population coverage. Care
provision becomes the main objective on which the surveillance could operate.
03
75% 62%outpatient inpatient
Inadequate linkage of morbidity with mortality data: The RCH program has
recently begun focusing on enhancing maternal and neonatal death review to
enable the identification of contributing factors and potential solutions to inform
health care service deliveries and prevent future deaths. However, maternal,
neonatal and child death surveillance and linking of mortality with morbidity reports
is not yet fully integrated. The data available with the vital registration system is
not yet shared/linked with IHIP, though this is possible through an Application
04
no mechanism for sharing or the unified use of the data. Even within the public
health system, there are a number of other institutions that are not yet involved
in surveillance. For example, the Central Government Health System, Railways,
Employee State Insurance (ESI) Corporation, and Defence related Army/Navy/Air-
force hospitals are not yet fully integrated into the Health Surveillance activities.
Vision 2035 envisages that surveillance will need to graduate from traditional data
entry systems based on vertical program implementation, to real-time data capture
from existing health records which are integrated using an UHID. Systems could be
enabled to transparently and safely exchange data based on standard protocols,
determined by the federated governance architecture. 14
Human resource challenges: The recruitment of human resources for State and
District Level Surveillance Units has been devolved to states, however, the response
of States to address these human resource gaps is varied. Health is a state subject,
while Health Surveillance is a national prerogative. Human resource vacancies and
staff capacity continue to plaque the system. The Joint Monitoring Mission 2015
8
reported 42% of vacancies at state and district levels and indicated that even at
the Central Surveillance Unit (CSU), positions tend to be filled by contract posts
or on deputation with individuals loaded with multiple other responsibilities. The
reasons for the lack of importance attributed to Public Health Surveillance by state
governments needs to be explored and addressed.
The relevant questions in this context are, “How do we ensure sufficient staff? Is
the supervisory and monitoring mechanism sufficient? How can we create and
sustain staff & structures?
Training of Public Health Core-Capacity: There are many examples of training
programs for public health professionals specifically in the area of surveillance.
For example, the United States Epidemic Intelligence Service through the Centre
for Disease Control (CDC) runs a two year Masters in Public Health course on
Epidemic Intelligence Service to develop a cadre of highly trained and skilled
epidemiologists for surveillance. The Public Health Agency of Canada runs a Field
Epidemiology Training Program to build public health capacity for responding to
urgent public health events. India lacks sufficient Public Health experts with this
expertise.
Relevant questions are: What additional skilling will existent or new HR require
in order to perform data analytics or use data science more efficiently? How can
these skills be expanded in scale and with speed? How much of resources could
Government at Central and State level invest in order to create and sustain this
expertise? How can partnerships with private medical colleges, public health
training institutes or Institutes of technology and management be leveraged for
this purpose? How can the Government objectively evaluate how skills of EIS
graduates are being utilised by the states, after course completion?
05
06
8
DGHS.Joint Monitoring Mission Report 2015
Programming Interface (API). Further, social and administrative barriers often lead
to under-reporting of deaths, even within the facilities. The linkage of mortality
and morbidity data even with infectious diseases is still limited.
How can we strengthen and integrate registration of vital events including birth,
marriage and death, in order to enhance surveillance?
Vision 2035: Public Health Surveillance in India: A White Paper 15Vision 2035: Public Health Surveillance in India: A White Paper
Limited use of digital, social and print media in surveillance: Social and print
media are increasingly being piloted for use in surveillance. A few states in the
country do have operational media scanning cells or media-advocacy initiatives
that help highlight disease outbreaks, or help identify a sudden increase in
hospitalisation or death due to an unusual event. These media sources can also
be used to promote disease prevention and containment actions at community
level during new infectious disease outbreaks (eg. During COVID-19, extensive
campaigns were used to promote social or physical distancing after hand-washing,
cough hygiene and wearing of masks), or to raise public awareness about danger
levels of indicators (eg. air pollution indices) and can help catalyse public health
responses.
How can we use social media for surveillance in India? Can we commission a
detailed impact evaluation to decide to what extent have social and print media
succeeded in making an original contribution to detecting early disease/outbreak
occurrences? How can India expand on its use of data science/“big data” strategies
for surveillance, that include social and print media (eg., Taiwan’s initial actions to
contain COVID-19 such as imposing a ban on flights from Wuhan, China and its
early travel restrictions were based on media reports of the outbreak in Wuhan,
much before WHO declared COVID-19 to be pandemic)
9
.
07
08
Limited focus on non-communicable disease surveillance: Non-communicable
disease (NCD) surveillance was introduced in many developed countries
almost 35-40 years ago. India faces the dual burden of non-communicable and
communicable diseases. The WHO predicted that by 2020, NCD would account
for 73% deaths and 60% of morbidity globally (WHO 2003). The IDSP has a division
of NCD that includes surveillance and other pilot programs which have focused
on diabetes, cardiovascular disease and cancers. The ICMR has played a crucial
role in enhancing surveillance of these three conditions through periodic surveys,
cancer registries and expansion of surveillance in newly formed regional centres
for cancer control. However, full integration of surveillance for NCD risk factors,
disease and death statistics, and surveillance of injury and accidents, air pollution
and its effects are yet to be included into surveillance.
How do we optimally use data collection from health records for NCDs? How
can we combine this information with periodic surveys on risk factors, disease
prevalence and death in order to provide a comprehensive picture and to enable a
continuum of care information, for the patient, the health care provider and policy
maker?
9
https://www.deccanchronicle.com/opinion/op-ed/130520/taiwan-has-just-65-active-440-total-covid-19-cases-despite-proximity.html 16Vision 2035: Public Health Surveillance in India: A White Paper
Fragmented and minimalistic approach in Occupational Health Surveillance:
Occupational Health Surveillance in India falls into two broad categories: Hazard
Surveillance and Health Surveillance. The NCDC has a division of Occupational
and Environmental Health. India has a National Institute of Occupation Health
(NIOH) in Ahmedabad, with regional institutes in Bangalore and Kolkata. With
ever growing urbanisation, increasing vehicular pollution and industrialisation,
Lead levels in air, water and soil are on the increase
10
. The NIOH has proposed
to conduct a prevalence survey of Lead toxicity, the commonest toxicity in urban
settings. Silicosis is the commonest occupational disease, seen commonly among
people working in mines and construction labour, most of whom belong to the
informal work sector
11
. The Employees State Insurance Corporation (ESIC) covers
most factory workers in the formal sector and a proportion of workers in informal
sector. Many formal sector workers also have other forms of health insurance that
cover hospitalisation expenses. However, despite this progress and availability of
occupational health data from these sources, Occupational Health Surveillance is
not a core component of India’s Public Health Surveillance. Silicosis is a notifiable
disease under The Factories Act, but it is not yet included under the Public Health
Act. Most doctors have minimal training on occupation health and disease.
Could India enhance and integrate Occupational Health Surveillance into its Public
Health Surveillance? What mechanism can we institute to ensure that national and
state governments facilitate consultations and collaboration between the Ministry
of Labour, Ministry of Mines and Ministry of Health in order to focus on priority
issues (eg., include Silicosis under the Public Health Act)? How can we ensure
routine monitoring of lead pollution in air, water and objects, and their toxicity, to
be included under surveillance? Could the most common, preventable conditions
under occupational settings be made notifiable and compensable (eg., noise-
induced deafness, muscular-skeletal disorders)? Finally, what other data sources
could we integrate in order to capture information on accidents and injuries (eg.,
medico-legal cases, road traffic accidents, etc.,)?
09
10
Patel K S, Ambade B, Sharma S, Sahu D, Jaiswal N K, Gupta S, Dewangan R K, Nava S, Lucarelli F, Blazhev B, Stefanova R, Hoinkis J.Lead
Environmental Pollution in Central India, New Trends in Technologies, Blandna Ramov, IntechOpen.January2010.DOI:10.5772/7590.
11
https://nhrc.nic.in/sites/default/files/NHRC_Interventions_on_Silicosis_27122016.pdf 17Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper
KEY CONSIDERATIONS
in Creating Vision 2035
4
17 18Vision 2035: Public Health Surveillance in India: A White Paper
KEY CONSIDERATIONS in Creating Vision
2035
Some of the key considerations in creating Vision 2035 for Public Health Surveillance
in India are listed here. Concerned stakeholders including policy makers and the
Government will need to address these questions in order to design and implement the
vision for Public Health Surveillance in 2035.
• Predicting/Forecasting and Preparedness for Epidemic Outbreaks for
communicable and emerging epidemics of non-communicable disease, both
re-emergence of known illnesses in different forms (influenza, MDR-TB), or new
disease outbreaks (NIPA virus, Corona virus, etc.,) or new geographic foci of
NCD.
• Guiding Prevention and Health Promotion Strategies: Identify new/hidden
reservoirs and sources of infection, block chains of rapid transmission and limit
the resulting morbidity, disability or death.
• Responding to Outbreaks and Guiding Future Programs of Disease
control: Institute standard protocols of a) characterising results beginning
with molecular tests, b) digitise results and ultimate action in real-time,
c) conduct genetic mapping to explore variations in the pathogen or the
susceptible host.
• Setting surveillance priorities: Could this include chronic and acute conditions,
especially in the context of occupational, environmental and nutritional health?
Could community, facility and system level components including health care
seeking and social determinants of health be included within Surveillance?
• Identifying and preparing the human resource capacity: How do we ensure
that we have a dedicated Public Health Cadre at block, district, state and
national levels, in adequate numbers and with composite competencies that
are regularly updated?
• Landscaping and strengthening laboratory capacity: How can we optimise
laboratory capacity within public and private sector? How do we strengthen
Point-of-Care diagnostics, self-testing protocols and referral networks to
reduce time taken to produce screening or diagnostic results that are reliable,
valid and useful to the patient and provider? How do we ensure that laboratory
results are smoothly amalgamated with relevant clinical and socio-demographic
information that contributes not only to better patient care but also to public
health actions?
What could be the goals of Public Health Surveillance?
What could immediate next steps include? Could it include: 19Vision 2035: Public Health Surveillance in India: A White Paper
• Digital Health interventions
• Integrated Communication Technology
• Science, Technology, Social and Business platforms
How can Public Health Surveillance leverage existing talent and
platforms?
• Unique Health Identifier
• Unified Health/Medical record
• Standard data sharing protocols
• Interoperability between systems and programs
How can we use routinely collect individual level patient data to
create population based datasets?
• Plant, animal and human disease statistics
• Environmental indicators
• Economic data
• Governance and Cooperative Federalism
• Data holding: Meta-data, data standards, case definitions, data protection, etc.,
• Patient care pathways and continuum of care: Individual, Family, course of
disease, etc.,
• Open mechanisms for inputs/outputs: Call centre, India Health Portal, Health
Apps, Insurance
Could Public Health Surveillance integrate different sources
of data for analyses, and how do we ensure an inter-sectoral
response?
What is the design of a Federal National Health Implementation
Architecture?
• Developing and mobilizing technologies and methodologies: Could there be
a horizon scanning for early warning signs through platforms such as WHO,
PROMED and others? What is the role of social media? How do countries
learn quickly on how to prevent, respond and act based on experiences of
new outbreaks in a different part of the globe? How do we ensure ‘Big data’
12
management and integrate Artificial Intelligence and machine learning into
Surveillance platforms?
• Coordination and governance: Policy, Technical, Managerial and Digital?
12
Healthcare big data refers to collecting, analysing and leveraging consumer, patient, physical, and clinical data that is too vast or
complex to be understood by traditional means of data processing. Big data is often processed by machine learning algorithms and
data scientists. https://partners.healthgrades.com/faq/what-is-healthcare-big-data 20Vision 2035: Public Health Surveillance in India: A White Paper
• Table 1 (Pg. 38) is a list of diseases targeted for elimination by the WHO. How
can India use this list to define their own list of diseases and time-lines for
Disease Elimination?
• Disease eradication appears to be a much more challenging goal and until date
has been achieved only with smallpox. However, with many diseases slated for
elimination by 2030, could the agenda for surveillance post-disease elimination
also be defined? For example, many developed countries are today facing re-
emerging epidemics of syphilis and other sexually transmitted diseases, which
were eliminated previously.
Which Diseases could India target for Elimination by 2030? What
could be the pathway to elimination?
• Community/public access
• Access to intellectual property
• Apex institutes to stimulate research on diagnostics and vaccines
• Publication of big data science and data analytics
• Business development for mass electronic manufacturers
How does Public Health Surveillance broaden data access for
relevant stakeholders to include all concerned while ensuring
required patient confidentiality? 21Vision 2035: Public Health Surveillance in India: A White Paper
5
THE BUILDING BLOCKS
FOR VISION 2035:
Public Health Surveillance
in India
21 22Vision 2035: Public Health Surveillance in India: A White Paper
THE BUILDING BLOCKS FOR VISION
2035: Public Health Surveillance in India
5.1 Governance: Principle - Develop an eco-system for surveillance
A federated governance system that is based on ensuring ‘public good’ and that pools
public health surveillance resources and information both for the ‘Centre’ and ‘States/
Union Territories’, is the foundation for Surveillance. A proposed architecture of future
surveillance is depicted in Figure 1. Governance includes three functions.
A political function that includes resource allocation and guidelines for
its use, enacting legislations relevant to control of epidemic diseases and
creating new policies.
A technical function that includes priority setting, protocols for disease
outbreak containment and management, case-definitions and setting
thresholds for labelling the type of disease outbreak/epidemic.
A managerial function that includes planning, implementation, monitoring
and evaluation. Each group is constituted as per existing guidelines.
Figure 1: The Architecture of Public Health Surveillance in 2035
FLW: Front-Line Worker, HWC: Health and Wellness Centre, DH: District Hospital, CHC: Community Health Centre,
MC: Medical Colleges, PHC: Primary Health Centre, ESIC: Employees State Insurance Corporation.
P
O
L
IT
IC
A
L T
E
C
H
N
I
C
A
L
NationalStateInformation for ActionInformation for Action
Program
Governance
Surveillance Information Platform
Unified e-Health Record
ELECTRONIC HEALTH RECORD &
ELECTRONIC MEDICAL RECORD
UHID
Hospital Management Information System
(e-Hospital)
Health Facilities
Public
· HWC
· CHC
· PHC
· MC
· DH · Hospitals
· Clinics
· Defence
· ESIC
· Railways Enumeration
UHID
FLW
Citizens
Health Portal
My Health App
Health Digi Locker
· Strengthened Research
· Apex Laboratories System
· Special Studies
· National Surveys
· Plant & Animal Disease Statistics
· Environmental Health Indicators
National Programs:
NACP/NTEP/IDSP
Occupational Health &
Injury Surveillance
Private Insurance & Govt.
Assurance Schemes data
Private Central Government 23Vision 2035: Public Health Surveillance in India: A White Paper
Surveillance itself functions on a single Surveillance Information Platform that amalgamates
all relevant information from multiple sources. Initially, this information can come from
existing vertical and integrated disease surveillance programs. However, over time,
this would be primarily driven from electronic health records (EHR) of populations and
medical records of patients, that are individualised and identified through the use of a
unique health identifier (UHID). Information from vertical and integrated disease control
programs, hospitals and health centres, laboratories and pharmacies, insurance related
routine medical check-up, PMJAY and other insurance records, and occupational health
surveillance will all be amalgamated into the EHR. In alignment with the Principle of
‘One-Health’ environmental health surveillance, plant and animal disease surveillance will
also be integrated into this Surveillance Information Platform. National surveys, special
studies and research will be used periodically to validate case definitions and to address
gaps within the EHR based surveillance.
Once the Surveillance Information Platform is fully functional, future Governance will
include the following:
The Priorities for surveillance and indicators of success are clearly defined and performance
is linked to Health Resource Allocation. Tools, thresholds and timelines for early warning
signs and outbreak reports are established, re-examined and redefined, periodically.
The performance of the Public Health Surveillance ecosystem is reviewed periodically
by an expert group represented by political, bureaucratic and scientific leadership. Key
stakeholders are periodically reviewed for their performance, measured by their use of
‘Information for Action’. The expertise and network intelligence that exists within apex
and research institutions is harnessed and specialist human resources are recruited,
developed and retained in adequate and appropriate strength. Continuous quality
improvement and legal mechanisms are in place to ensure global/regional leadership
of India’s public health surveillance. Finally, novel partnerships are established with
developed and developing countries for continued learning and development, detecting
emergence of new pathogens, identifying new phenotypes and genotypes of known
pathogens, for monitoring anti-microbial resistance, new diagnostics, nanotechnology
and its applications, etc.,
5.2 Information Systems linked with robust lab networks as data
sources for Surveillance
New data sharing mechanisms ensure that Surveillance does not replace existing vertical
and integrated programs, but amalgamates the data on a ‘Surveillance Information
Platform’ in near real-time using data-sharing mechanisms, rather than traditional data-
entry systems. In order to enable this, the use of a Unique Health Information Identifier
(UHID) number, as envisioned in the National Digital Health Blueprint (2019), becomes
universal. This facilitates linkage between clinical, laboratory and pharmacy related data,
allows individual level data capture on disease diagnosis, management and outcomes,
as well as analysis of disease patterns, prevalence and trends at the population level.
Additionally, the UHID reduces duplication and enables analysis of new trends by
individual socio-demographic characteristics and emerging risk factors, and appropriate 24Vision 2035: Public Health Surveillance in India: A White Paper
allocation of resources with measurement of disease burden. All information is captured
from an EHR or a standard format, that is again universalized and standardized for use
within the public and private health system, as well as other points of contact with
service delivery, such as those provided outside the traditional health system, including
rehabilitation services, social and welfare services, etc., Additionally, data collection
leverages new technologies including the use of hand-held devices, rapid throughput
screening devices in ports and entry points, mobile platforms and digital technologies,
call-centre approaches, new ‘Point-of-Care’ screening and diagnostic tests that can be
used for an array of diseases, self-collected and tested swabs, saliva and urine tests that
can be done at home or in community settings, but with automated data capture. Data
outputs from laboratories, pharmacies, health institutions and the insurance sectors, are
captured directly in near real-time, compiled using standard protocols, and available for
access, as and when needed. Data sharing agreements are configured and contracted,
with due consideration to privacy and confidentiality of the individual.
5.3 Data Analytics (including Predictive Analytics)
Definitions of disease are standardized for surveillance that are agreed upon by clinician,
researcher and epidemiologist, and between veterinary, plant and human sciences, in
alignment with the ‘One-Health’ principle are universally utilised. Interoperability or free
exchange of information from different systems and between different disease control
program platforms are established to ensure that data is linkable and de-identified, stored
safely and is available for refined and advanced analysis. New risk factors that emerge
from research are rapidly integrated into models for disease prediction, especially for
non-communicable disease (NCD) conditions. New Data Science analytical tools and
methodologies including molecular epidemiology, genomics, mathematical modelling,
prediction techniques and artificial intelligence are integrated for use within Surveillance
Systems to inform public health responses and policy.
These may include:
Automated systems that flag/alert
authorities of potential threats based
on predefined thresholds for identified
diseases
Analysis by researchers, modellers
and others, which can help inform and
improve case definitions
Predictive systems which flags authorities
based on patterns of symptoms
Tools for performance management
measurements 25Vision 2035: Public Health Surveillance in India: A White Paper
5.4 Information for Action: Principle - ‘For Public good’
Public Health Surveillance undergoes a paradigm shift from being visualized as a core
Government function, to one that is ultimately aimed at making relevant information
available to the common citizen for public good. New dissemination techniques include
the use of health informatics, electronic and digital platforms, social media and individually-
accessed digital apps, with password-protected information. Health information ethics,
patient privacy and confidentiality will be an integral part of any process which uses these
tools for Public Health Surveillance.
New stakeholders are included. In addition to the patient, parent/guardian and the
practitioner, the private or public institutions (that are academic, service-oriented,
research-focused, product development-oriented or policy-centred), the policy maker,
the press and the politician will be included. However, only meaningful, select and
relevant information will be made available to stakeholders on an as needed basis, in
order to ensure patient confidentiality.
Surveillance is ‘Information for Action’. Examples of action at different levels is illustrated
below. This is not an exhaustive list.
Citizen Level: Preventive actions to limit disease transmission and optimize
health outcomes (actions for self-protection, self-quarantine, self-testing, self-
care, timely access to the right services, adherence to treatment, etc.)
Block/District level: Outbreak investigation, Active and passive case-finding,
Contact tracing, Isolation of index, Quarantine of presumptive patients, Social/
physical distancing, Limiting air, water, soil, food, blood and its products and
vector borne transmission, Treatment of confirmed cases/contacts, Chemo/
Immuno-prophylaxis for susceptible individuals, etc.,
State/National level: Legislation, Resource Allocation, Monitoring trends,
Disseminate meaningful information to relevant stakeholders, Monitor actions
at different levels, etc.,
International level: Reporting under International Health Regulations and for
Public Health Emergencies of International Concern.
For NCD and Occupational Health: Minimise exposure to known risk factors,
regulate sources of environmental pollution, dedicate resources, inter-sector
collaboration. 26Vision 2035: Public Health Surveillance in India: A White Paper
Response Team
Administration &
Policy Makers
Automated
Alert System
Plant & Animal
IndicatorsFront Line Workers
Citizens
Health Care
Provider
Laboratory
Electronic
Health Record
Electronic
Lab Record
Electronic Personal
Assesment Record
Surveillance
Information Platform
Data Warehouse
Pharma Sales
Data
Electronic
Medical Database
Environmental
Indicators
National
Research
& Surveys
Media Scans
Gov. Data
Scientists
and Researchers
National
Programs
Citizens
Open Data
POLITICAL
Governance
TECHNICAL
NATIONAL
MANAGERIAL
STATE
Information
for Action
UHID
Enumeration
Data AnalyticsService Provision Electronic Data Interchange & Collation
Diagnostics
Seek\Receive Care
Enroll Citizen
Figure 2: The Proposed Flow of Information for Public Health Surveillance in 2035
The proposed flow of information is depicted in Figure 2. 27Vision 2035: Public Health Surveillance in India: A White Paper
6
STEPS TOWARDS
ACHIEVING VISION 2035:
Public Health Surveillance
in India
27 28Vision 2035: Public Health Surveillance in India: A White Paper
STEPS TOWARDS ACHIEVING VISION
2035: Public Health Surveillance in India
Drawing from India’s past experience and global best practice, this document recommends
steps to building Public Health Surveillance in India. The steps are not in order of priority.
However, they have been presented as clusters and in a cycle of events, as depicted in
Figure 3.
6.1 Raise the profile of Public Health Surveillance
Public Health Surveillance in India is often considered as a separate activity, not related
directly to health care service delivery. It is sometimes viewed as a stand-alone activity,
with different institutions responsible for different aspects, as depicted in Figure 5
(Pg. 43). It is important to raise the profile of Public Health Surveillance in India and to
position Public Health Surveillance as a tool for public good. In order to enable this,
Information for Action may be made available to multiple stakeholders, including the
citizen and the political and bureaucratic leadership at the central, state and district level.
It is of paramount importance for an effective and responsive governance structure to
be set up immediately. Periodic coming together of this leadership will be important to
charter a way forward, as well as to deal with Public Health Emergencies of International
Concern, as and when they arise. The governance team will guide the development of
the blueprint or action plan that needs to be developed. The suggested architecture for
PHS in 2035 is depicted in Figure 1 (Pg. 22) and Figure 2 (Pg. 26).
Figure 3: The Way Forward: Public Health Surveillance in India
Meaningful
Information
Relevant
Stakeholders
Responsive,
Timely &
Appropriate
Actions
Citizen Centric
Political & Technical
Leadership
Digital Technological
Leadership
Managerial
Leadership
Policy
Leadership
Improve Core
Functions
Improve Support
Functions
Improve System
Attributes
Raise the Profile
of Public Health
Surveillance in India
Define scope.
Identify broad
categories
Prioritise Diseases/
Conditions for
Surveillance Use STEPwise
approach to integrate
NCD Surveillance
Encourage
Innovations
Strengthen Lab
Capacity and
Referral Networks
Align with Ayushman Bharat:
Enhance Community based
surveillance
Streamline data
collection techniques
Strengthen data
analysis techniques
Systematically
disseminate
Information for
Action 29Vision 2035: Public Health Surveillance in India: A White Paper
13
The Internet of Things (IoT) refers to a system of interrelated, internet-connected objects that are able to collect and transfer data
over a wireless network without human intervention. https://internetofthingsagenda.techtarget.com/definition/Internet-of-Things
IoT. An IoT system consists of sensors/devices which “talk” to the cloud through some kind of connectivity. Once the data gets to the
cloud, software processes it and then might decide to perform an action, such as sending an alert or automatically adjusting the
sensors/devices without the need for the user. https://www.leverege.com/blogpost/iot-explained-how-does-an-iot-system-actually
work
6.2 Create/Strengthen an Independent Health Informatics Institute
Public health informatics has an essential role in data collection, collation, analysis and
transmission for public health surveillance and related actions. A dedicated Independent
Health Informatics Institute will need to be created to support and guide innovations and
analytic activities, including the use of Internet of Things (IoT)
13
surveillance activities. It
is essential for both the centre and states to recognise the importance of Public Health
Information for Action and allocate resources and dedicate appropriate technology to
manage Health Information for Action.
6.4 Use a WHO STEPwise approach to include NCD Surveillance
Surveillance for NCD has been fragmented. The WHO suggested the STEPwise approach,
that is inclusive of death, disease and risk factors. Tables 3a and 3b ( Pg. 43) in the annexure
depict this approach. The STEPwise approach can be implemented beginning with Health
and Wellness Centres in India, wherein front-line workers and Community Health Officers
6.3 Define the scope of surveillance into broad categories of diseases/
conditions, keep it simple and strategic
India has traditionally focused on Surveillance for Communicable/Infectious Diseases.
Though initiatives are in place for NCD, Occupational Health, Injury and Environmental
Health Surveillance, these are not yet given adequate surveillance attention. In order
to facilitate strengthening of these areas, it may be important to create/identify nodal
structures for different diseases and conditions. As an example, the Department of Disease
Control, Ministry of Health, Thailand classified and focused on five main categories of
disease that were prioritised for Health Surveillance: a. Acute Communicable Disease,
b. HIV and TB, c. Non-communicable disease, d. Injury, e. Occupational and environmental
disease. India may decide to follow these same principles. Currently, surveillance is
in place for the first three disease groups/conditions. The list of diseases under the
Integrated Disease Surveillance Program is shown in Table 2. Additionally, HIV and
TB function as vertical programs, with their own surveillance systems. Inter-ministerial
cooperation between ‘labour’ and ‘health’ is essential to expand on Occupational
Disease Surveillance and to capture ‘injuries’. India can redefine the scope and priorities
for disease surveillance and establish /strengthen structures that can be held accountable
for each of the prioritised disease categories. The exercise can be repeated, at least once
every three to five years. In addition to disease based surveillance, response protocols
and mechanisms for event based surveillance especially for Public Health Emergencies of
International Concern, may be strengthened. 30Vision 2035: Public Health Surveillance in India: A White Paper
6.5 Prioritise Diseases/Conditions that will be the focus for
Surveillance/Disease Elimination
India can use multiple criteria, based on available information to prioritise diseases and
conditions under each of the five broad categories that were listed above in the Thailand
example. As an example, Germany used ten criteria including a. incidence, b. work
and school absenteeism, c. health care utilisation, d. chronicity of illness and sequelae,
e. case fatality rate, f. proportion of events requiring public health action, g. trend, h. public
attention including political, media and public perception, i. prevention possibilities and
j. treatment possibilities for prioritising diseases for surveillance, as depicted in Table 4
(Pg. 41). India could use similar criteria or adapt the same, based on local context. WHO
has listed diseases for Elimination by 2025 and 2030, as depicted in Table 1 (Pg. 38). India
could create its own list of diseases slated for elimination by 2030. India could adapt/design
the prioritization criteria based on the context of each state or district, given its diversity.
6.6 Improve Core Support Functions, Core Functions and System
Attributes
Revati K Phalkey et al in 2015 published, “Challenges with the implementation of an Integrated
Disease Surveillance and Response (IDSR) system: systematic review of the lessons learned”
highlighting the importance to first improve core support functions including health system
support, workforce support and technological support, as depicted in Figure 6 (Pg. 44).
Once this is taken care of, enhance core functions of surveillance including case definition,
case confirmation, case registration, case notification, data management, data analysis,
outbreak preparedness, outbreak detection and response and feedback. All the while, it
would be important to focus on improving system attributes including Simplicity, Flexibility,
Timeliness, Completeness, Consistency, Representativeness, Acceptability, Data Accuracy,
Sensitivity, Positive Predictive Value and Stability.
6.7 Streamline data sharing, analysis, dissemination and use for action
The first and foremost pre-requisite for a unified Surveillance system is the need of
a unique health identifier (UHID) for every individual. This will not only help to link
Syndromic, Presumptive and Laboratory records that are currently used, but can also
be potentially used to link morbidity and mortality data. It also allows for better NCD
surveillance - for incidence/prevalence and understanding health outcomes - as well
as for informing allocation of resources. India has made great progress by achieving
almost universal coverage of the UID (Aadhar). There is potential to use UID or a similar
system to ensure that every individual has a UHID, which will enable the patient and
health care provider to have complete information on the health and disease status
of the individual. The access to this information can be controlled by incorporating
watch over the health and wellness of a fixed population, with digitised person-centred,
family based records. Personal health records, hospital and insurance records and surveys
can complement this information. 31Vision 2035: Public Health Surveillance in India: A White Paper
6.8 Encourage Innovations
India is well known for its innovative approaches in Health and other sectors. Innovation
could be encouraged within Public Health Surveillance as well. As an example, Public
Health Surveillance England mentioned steps where innovation can be explored within the
public health surveillance loop to include new collection techniques, new case definitions
or new risk factors/groups, new Point-of-Care diagnostics and screening tools/devices,
new analytical tools, new dissemination techniques, new stakeholders, new evidence/
research findings, as depicted in Figure 8 (Pg. 46). It would be necessary to identify
opportunities for implementation of these innovations within districts/states to learn from
and then ensure successful scale up and integration into the Public Health system.
Barker I, Brownlie J, et al in their foresight document entitled, “Infectious Diseases:
preparing for the future. A vision of future detection, identification and monitoring
systems”, developed a framework for future detection, identification and monitoring
systems, which is depicted in Figure 9 (Pg. 47). The framework explored consideration
of the analysis of future threats, the analysis of societal contexts and the reviews of
future science to be contributors of an evaluation of future Detection, Identification and
Monitoring (DIM) systems. The future DIM systems would predict and suggest public
health actions necessary for disease control.
6.9 Align with Ayushman Bharat
The Health and Wellness Centres present a unique opportunity to strengthen community
based surveillance at the primary health care level, by capacitating front-line health
personnel to perform syndromic reporting for infectious disease and screening for risk
factors or for disease markers for common NCD and communicable diseases, using basic
verbal screening tools or Point-of-Care diagnostics and devices. Additionally, information
captured under the PMJAY assurance scheme and private and public insurance sector
insurance schemes can also be amalgamated for disease surveillance of hospitalisation
episodes.
one-time passwords (OTP). One will need to be cognisant of the rulings of the judiciary
on the pertinent use of the UID for health and social protection. The UHID and EHR
become core building blocks in order to streamline data sharing. Figure 7a and 7b
(Pg. 45). depict core building blocks used in different contexts. Actions dependent on
the use of social, electronic, print and digital media can be explored to build on data
analytics, dissemination and for making meaningful information available for relevant
stakeholders. Actions in response to epidemic disease outbreaks, high or clustering of
NCD prevalence and occupational diseases have been mentioned previously. 32Vision 2035: Public Health Surveillance in India: A White Paper
6.10 Strengthen laboratory infrastructure, referral networks and
community based surveillance
A well-functioning and robust laboratory system at various levels of healthcare is critical
to establishing an efficient disease surveillance program. States may have decentralised
diagnostic facilities in order to conduct surveillance of epidemic prone diseases. The IDSP
has developed district public health laboratories that are being strengthened under the
National Health Mission. These efforts may be accelerated and scaled up. The need for
the rapid, accurate, affordable and robust diagnostics is obvious. The WHO released the
first edition of essential diagnostics list (EDL) in May 2018. The ICMR finalised the country’s
first National Essential Diagnostics List (NEDL), a year later. NEDL has considered all
levels of health care – village level, primary, secondary and tertiary care and builds upon
the Free Diagnostics Service Initiative and other diagnostics initiatives of the Ministry
of Health to provide an expanded basket of tests at different levels of the public health
system. Availability of quality assured diagnostics at various levels of healthcare is critical
for disease prevention, control and surveillance.
Primary Health Centres would need strengthened capacity of front-line workers for
community-based screening for presumptive and active cases, active case-finding,
contact tracing, to promote barriers to disease transmission including social/physical
distancing, hand-washing, cough hygiene, use of toilets and safe drinking water, etc., as
relevant. Laboratories at the primary care level can be strengthened with Point-of-Care,
community-based or self-testing kits, in order to screen for or confirm disease, that may
be endemic or new, within local geographic settings.
Block level labs may be strengthened in order to increase the efficiency of public health
interventions and to decrease the load on district and state level labs. Accurate diagnoses
of common endemic diseases in the region, based on common syndromes (eg., Acute
Febrile Illness) is feasible in block/district level labs. Block level labs can confirm diagnosis
early, during disease outbreaks and after the outbreak and thus support the right decisions
related to action and intervention in a timely manner.
Additionally, it would be important to strengthen referral networks to ensure that
primary care benefits from clinical and laboratory disease/risk factor confirmation that
is made widely available at block and district level. This can be effectively implemented
by putting into place PoC screening and diagnostics; making available and accessible
community-based/ home-based testing kits, activating blood/ urine/ saliva/ sputum/ hair
based sample collection, transportation, testing and reporting mechanisms, and rapid
throughput screening or hand-held devices, in addition to enabling front-line and mid-line
health personnel with smart phone apps and mobile based and digital technologies.
It would be important to strengthen nodal institutions with human resource, infrastructure,
equipment and supplies for genotype, phenotype, detection of pathogenic mutants and
for antimicrobial resistance. Additionally, these can be made responsible and accountable 33Vision 2035: Public Health Surveillance in India: A White Paper
14
Jian S W, Chen C M, Lee C Y, Liu D P. Real-Time Surveillance of Infectious Diseases: Taiwan’s Experience. Health Secur. 2017 Mar/
Apr;15(2):144-153.DOI: 10.1089/hs.2016.0107.PMID: 28418738; PMCID: PMC5404256.
An illustrative example Surveillance for Infectious disease alone is the Public Health
Surveillance of Taiwan
14
, illustrated in Figure 10 (Pg. 48).
Figure 4: Integration of PHS into Ayushman Bharat: 3-tiered Approach
Integrated Health Information Platform
Pheno/genotypes,
molecular-based tests,
pathogen mutants,
resistance patterns
Laboratory confirmation,
Clinical case definition
Syndromic/Presumptive
Reporting for ID
Screening data for NCD
Strengthen
Lab capacity
Epidemic Threshold
Trend Analysis
New Variant/concern
Adherence to
Standards
Strengthen
referral networks
Strengthen
community level
surveillance
Apex
Institutes
District Hospitals
Primary Health
Centres
Health & Wellness
Centres
PMJAY
Information
for quality assurance of molecular, serological and microbiological testing in partnership
with intermediate and state level reference laboratories. Private institutions can be
engaged through a collaborative and mutually beneficial framework. Finally, it would be
important to task and fund institutions to ensure Continuous Quality Improvement. The
integrations into Ayushman Bharat and the three-tiered approach to lab strengthening
are depicted in the Figure 4. 34Vision 2035: Public Health Surveillance in India: A White Paper 35Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper
CONCLUSION7
35 36Vision 2035: Public Health Surveillance in India: A White Paper
CONCLUSION
In conclusion, India’s Vision 2035 for Public Health Surveillance envisions integration within
the three-tiered health system, strengthened community based surveillance, expanded
referral networks and enhanced laboratory capacity. The EHR becomes the main basis
of surveillance and is complemented by periodic national/state/district level surveys,
special studies and research in order to reconcile the threshold and redefine standard
definitions of cases, as disease patterns evolve. Surveillance is not solely dependent on
individual disease driven active or passive surveillance systems, though these may remain
important contributors to surveillance information. The building blocks for this vision are
an interdependent federated system of Governance between Centre and States, new
data sharing that is not dependent on traditional systems of data entry, but one that
is positioned over and above existing disease surveillance programs. Surveillance uses
new analytics, health informatics and data science and innovative ways of disseminating
‘Information for Action’. This will further thrust India to be a global/regional leader in
Public Health Surveillance. 37Vision 2035: Public Health Surveillance in India: A White Paper
ANNEXURES
Vision 2035: Public Health Surveillance in India: A White Paper37 38Vision 2035: Public Health Surveillance in India: A White Paper
TABLE 1 WHO list of Diseases slated for Elimination and their Timelines
Intervention Disease
Eradication:
Worldwide
reduction to zero
Interruption of
local transmission
Elimination as
a public health
problem
Small pox
Polio
Yaws
Dracunculiasis
Malaria
Measles
Rubella
Leprosy
Chagas
Sleeping sickness
Onchocerciasis
Schistosomiasis
Visceral Leishmaniasis
Cholera
Lymphatic Filariasis
Trachoma
Mother-to-Child
Transmission: HIV and
Syphilis (and HepB)
Maternal and neonatal
tetanus
Rabies
Soil transmitted
helminths
Global
Global
Regional: Americas
Regional: Africa
Global
Regional
Regional: Indian
sub-continent
20/47 endemic
countries
Global
Global
Global
Global
Global
Global
10 years from 1966
2014
To be decided
To be decided
2030
2020
2020
2020
2015
2022 Latin America
and 2025 Africa
2025
2020
2030
2020
2020
2030
2020
2030
2030
RegionTarget Dates Vision 2035: Public Health Surveillance in India: A White Paper 39
TABLE 2 Diseases under Integrated Disease Surveillance Program
L form
1. Dengue / DHF / DSS
2. Chikungunya
3. JE
4. Meningococcal Meningitis
5. Typhoid Fever
6. Diphtheria
7. Cholera
8. Shigella Dysentery
9. Viral Hepatitis A
10. Viral Hepatitis E
11. Leptospirosis
12. Malaria: PV, PF
1. Acute Diarrhoeal Disease (Cholera)
2. Bacillary Dysentery
3. Viral Hepatitis (A/E)
4. Enteric Fever
5. Malaria (PV, PF)
6. Dengue / DHF / DSS
7. Chikungunya
8. Acute Encephalitis Syndrome (JE)
9. Meningitis
10. Measles
11. Diphtheria
12. Pertussis
13. Chicken Pox
14. Fever of Unknown Origin (PUO)
15. Acute Respiratory Infection (ARI) / Influenza Like Illness (ILI)
16. Pneumonia
17. Leptospirosis
18. Acute Flaccid Paralysis < 15 Years of Age
19. Dog bite
20. Snake bite
21. Any other State Specific Disease (Specify)
22. Unusual Syndromes NOT Captured above (Specify clinical
diagnosis); eg., scrub typhus
Diseases under Presumptive (P form) Surveillance 40Vision 2035: Public Health Surveillance in India: A White Paper
NCD
Measures
Risk factors
(the future)
Diseases
(the present)
Deaths
(the past)
Core
Expanded
Core
Optional
(examples)
Questionnaire-
based report on key
behavioural risk factors
Hospital or clinic
admissions, by age
and sex
Death rates by age
and sex
Socio-economic and
demographic variables,
years of education, tobacco
and alcohol use, physical
inactivity, intake of fruit and
vegetables
Ethnicity, Income,
Education, Household
indicators, Dietary patterns
Other health-related
behaviours, mental health,
disability, injury
Questionnaires plus
objective physical
measurements
Rates and principal
condition by age. sex
and principal conditions:
communicable diseases,
NCDs and injury
Death rates by age,
sex and broad cause of
death (verbal autopsy)
Measured weight
and height, waist,
circumference,
blood pressure
Hip circumference,
pulse rate
Timed walk,
pedometer, skinfold,
thickness
Questionnaires plus
objective physical
measurements plus bio-
chemical measurements
Age, sex and cause-
specific disease
incidence or prevalence
Death rates by age, sex
and cause of death
(death certificate)
Fasting blood
sugar, total
cholesterol
HDL-cholesterol,
triglycerides
Oral glucose
tolerance test,
urine examination
Step 1
Step 1 (Self Report)
Step 2
Step 2 (Physical)
Step 3
Step 3 (Biochemical)
TABLE 3a
TABLE 3b
The WHO STEPwise approach to NCD surveillance
STEPS approach to risk factor assessment 41Vision 2035: Public Health Surveillance in India: A White Paper
No.
1
2
3
4
5
6
7
<1/100 000
This pathogen
causes a negligible
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a negligible
proportion of health
care utilisation due
to an infectious
illness
This pathogen
causes a negligible
amount of chronicity
or persistent
sequelae (estimate
prevalence of those
being <0.1/100 000
population)
<0.01%
A small proportion of
the estimated total
number of events or
exceptional events
require public health
actions (<25%)
Diminishing incidence
rates
Incidence
(including illness
and symptomatic
infection)
Work and school
absenteeism*
Health care
utilisation (primary)
Chronicity
of illness or
sequelae*
Case fatality rate**
Proportion of
events requiring
public health
actions (see
Note 2 for
explanation)**
Trend**
1-20/100 000
This pathogen
causes a small
to moderate
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a small
to moderate
proportion of
health care
utilisation due to an
infectious illness
This pathogen
causes a small to
moderate amount
of chronicity or
persistent sequelae
(estimated
prevalence of those
being 0.1-1.0/100
000 population)
0.01-1%
A moderate to
large proportion of
the estimated total
number of events
require public
health actions (25-
75%)
Stable incidence
rates
>20/100 000
This pathogen
causes a large
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a large
proportion of
health care
utilisation due to an
infectious illness
This pathogen
causes a large
amount of
chronicity or
persistent sequelae
(estimated
prevalence of those
being >1.0/100 000
population)
> 1%
Almost all of the
estimated total
number of events
require public
health actions
(>75%)
Increasing
incidence rates
CriteriaScoring Values
-110
TABLE 4
Criteria for scoring to Prioritise diseases/conditions for
surveillance 42Vision 2035: Public Health Surveillance in India: A White Paper
8
9
10
Risk perception of
this pathogen by
general public is low
and it is not high on
political agenda
Preventive potential
seems low or the
disease does not
require prevention or
effective prevention
strategies are well-
established; no
need for significant
strategy modification
Medical treatment is
rarely necessary or
effective regimens
are well-
established; no
need for significant
modifications
Public attention
(including political
agenda and public
perception)*
Prevention
possibilities and
needs (including
vaccines)**
Treatment
possibilities and
needs (including
AMR)**
Risk perception
of this pathogen
by general public
is moderate and
informal political
expectations/
agenda is present
Measures for
prevention are
established but
there is need to
improve their
effectiveness
Medical treatment
regimens are
established but
there is need
to improve their
effectiveness
This pathogen
implies international
duties or its risk
perception by
general public
is high or it is
explicitly high on
political agenda
Need for
prevention is
established but
currently no
effective preventive
measures are
available
Need for medical
treatment is
established,
but currently no
effective treatment
is available or AMR
limits treatment
options
*Assessed against the total burden of infectious diseases
**Assessed for each particular pathogen in question – takes into consideration the availability and adequacy of treatment for each case
of illness.
Source: Yanina Balabanova, Andreas Gilsdorf, Silke Buda, et al, “Communicable Diseases Prioritised for Surveillance and Epidemiological
Research: Results of a Standardized Prioritization Procedure in Germany, PlOS One October 2011 43Vision 2035: Public Health Surveillance in India: A White Paper
IHIP
SI-NACO
Nikshay
RCH portal
Vital Event Registration
Other
CSU/SSU/DSU
CTD
NACO
NHM/Min. of Health
Directorate of Health
Dept. of Health
Registrar of births/deaths
NVBDCP
ICMR
CBHI
26 Regional ICMR
Institutes
8 NCDC Branches
State Reference Labs
District level labs.
Referral linkages for
specimen collection,
transportation & reporting
systems.
Centre
State
District
Technology
Platform
GovernanceTechnical Support
& Research
SI: Strategic Information, NACO: National AIDS Control Organisation, RCH: Reproductive and Child Health, CSU: Central
Surveillance Unit, SSU: State Surveillance Unit, DSU: District Surveillance Unit, CBHI: Central Bureau of Health Intelligence
FIGURE 5 Existing Structure for Public Health Surveillance 44Vision 2035: Public Health Surveillance in India: A White Paper
Source: Revati K Phalkey, Shelby Yamamoto, Pradip Awate, Michael Marx, “Challenges with the implementation of an Integrated
Disease Surveillance and response System: systematic review of the lessons learned, Health Policy and Planning 2015
Health
Systems
Support
System
Utility
Work
Force
Support
Technical/
Technological
Support
• Simplified system
structure
• Coordination with
other sectors and
health programs
• Resources (Financial,
human, logistics and
equipment)
• Leadership (National
& District levels)
• Legal Frameworks
IMPROVED SYSTEM
ATTRIBUTES
IMPROVED CORE
FUNCTIONS
IMPROVED SUPPORT
FUNCTIONS
• Pre and in-service
training for
surveillance and lab
staff
• Supervision
• Retain trained staff
Improved Core
Functions
1. Case Definition
2. Case Confirmation
3. Case Registration
4. Case Notification
5. Data Management
6. Data Analysis
7. Outbreak
Preparedness
8. Outbreak Detection
and Response
9. Feedback
Improved System
Attributes
1. Simplicity
2. Flexibility
3. Timeliness
4. Completeness
5. Consistency
6. Representativeness
7. Acceptability
8. Data Accuracy
9. Sensitivity
10. Positive Predictive Value
11. Stability
• Equipment
(Laboratory, IT,
Transport and
Communication)
• Job Aids (Deadlines,
guidelines,
definitions, reporting
formats etc.)
• Standard Operation
Procedures (Labs
and Outbreaks)
Improved
System
Performance
FIGURE 6
Improved Health Systems Support, Core Functions & System
Attributes 45Vision 2035: Public Health Surveillance in India: A White Paper
Health Unique Identity Number
Standards
Data collection: Mobile app/India
Health Portal/Call centre
Interoperability HIE, NHS
Access and Control by Citizen
Stakeholders
Interdependent
Federated Architecture
between States and
Centre
Technical, Managerial
and Policy Leadership
A skilled workforce
A common lexicon
Global surveillance needs
Data management, storage and
analysis
Informatics, including information
technology
Data access and use
New Evidence/Research
New Case Definition/Risk Factors/
Groups
New Collection Techniques
New Analytical Tools
New Dissemination Techniques
New Stakeholders
India’s Digital Health
Governance
US PHS for the 21st
century
New Data Collection & Sharing Mechanisms
Enhanced Use of New Data Analytics
PHS England
FIGURE 7a
FIGURE 7b
Examples of Key Building Blocks for Surveillance
Key Building Blocks for Vision 2035: PHS in India
Data
Science
Artificial
Intelligence
Machine
Learning
Advanced Health Informatics &
Methods of Data Dissemination
Unique Health
Identity (UHID)
Electronic Health
Records
Amalgamation of
existing disease
surveillance
Complemented by
periodic surveys 46Vision 2035: Public Health Surveillance in India: A White Paper
• New collection techniques could include hand-held devices, mobile platforms and digital
technologies.
• New screening and diagnostic tools could include ‘Point-of-Care’ tests, self-collected and
tested swabs, saliva and urine tests that can be done at home or in community settings,
captured in near real-time and accessed when needed.
• New definitions would primarily include a standardization of definition between clinician,
researcher and epidemiologist, or between veterinary, plant and human sciences.
• New risk factors will emerge as new evidence emerges from research. High levels of
cholesterol were considered until recently to be risk factors for cardiovascular disease, but
this relationship is under question currently.
• New analytical tools can include mathematical modelling, prediction techniques, artificial
intelligence and big data analysis.
• New dissemination techniques include social media and other electronic or digital
platforms.
• New stakeholders have already been previously listed and include the patient/parent,
the practitioner, the private or public institution which may be academic, service-oriented,
research, product development-oriented or policy-centred, the policy maker, the press and
the politician.
• New evidence/research needs no further explanation.
Source: Adapted from Dept. of Health, PHE Transition Team, “Towards a Public Health Surveillance Strategy for England” 2012 India
can consider a seventh new step and include ‘new screening and diagnostic tools’ after new data collection.
FIGURE 8 The Public Health Surveillance Loop
New Collection
Techniques
New Dissemination
Techniques
New Analytical
Tools
New
Stakeholders
Health Care System
Surveillance
Quality Improvements
New case definition
or new risk factors/
groups
New Evidence/
Research Findings
Analysis,
Interpretation
SURVEILLANCE
REPORTING,
INFORMING
DISSEMINATION, FEEDBACK,
RECOMMENDATIONS AND REVIEW
HEALTH CARE SYSTEM
EventData
ActionInformation 47Vision 2035: Public Health Surveillance in India: A White Paper
Source: Barker I, Brownie J, et al “Foresight. Infectious Diseases: preparing for the future: A Vision of Future Detection, Identification
and Monitoring Systems” Office of Science and Innovation, London,2006
ACTION
PLAN
Evaluation of future DIM Systems -
User Challenges
Detection
Identification
Monitoring
Analysis
of Future
Threats
Analysis
of Societal
Contexts
Reviews
of Future
Science
UC 1:
Data Mining
and Data Fusion
- to detect new
diseases
UC 3:
Hand Held
Diagnostics
Device
UC 2:
Genomics and
Post Genomics
to characterise
new diseases
UC 4:
Fast through-
put screening
at ports and
airports
FIGURE 9 Framework for Future Detection, Identification and
Monitoring Systems 48Vision 2035: Public Health Surveillance in India: A White Paper
Cloud data
exchange
platform
Data
validation
Data
warehouse
- Case investigation
- Feedback laboratory diagnosis
EMR
server
LARS
server
Clinical lab
positive results
HospitalsTaiwan CDC
Laboratory information
management system
Hospital
information
system
Physicians Infection control
health care workers
Electronic
medical record
Data
visualization
Web-based
analytical system
Open data
Source: Jian SW, Chen CM, Lee CY, Liu DP. Real-Time Surveillance of Infectious Diseases: Taiwan’s Experience. Health Secur.
2017;15(2):144–153. DOI:10.1089/hs.2016.0107
FIGURE 10 Real-Time Surveillance of Infectious Diseases in Taiwan 49Vision 2035: Public Health Surveillance in India: A White Paper
India launched the Integrated Disease Surveillance Project/Program (IDSP) as a decentralized, state
based surveillance program in 2012. The intent of the program is:
• to detect early warning signals of impending outbreaks
• to help initiate an effective response in a timely manner
• to provide essential data to monitor progress of on-going disease control programs
• to help allocate health resources more efficiently
There is a list of more than 33 acute conditions covered under the IDSP. This list is provided in Table
2. There are three levels of surveillance under this program.
These three levels of surveillance align with the three-tier health system within the country, that
includes sub-centres (SC) and primary health centre (PHC) facilities for provision of primary health
care, community health centres (CHC) and sub-divisional hospitals/block CHC and district hospitals as
secondary levels of care and medical colleges and apex institutes as tertiary care centres.
In addition, many states have also instituted ‘Media Scanning and Verification Cells’ as a function of
the SSU, and very often, these serve as the ‘Early Warning System’ for a political and programmatic
response to a disease outbreak.
The IDSP has categorized the public health response in order to address concerns raised through
surveillance by three levels:
Diagnosis is made on
the basis of symptoms/
clinical pattern observed
by paramedical personnel
and members of the
community. Seven main
conditions are reported
under this including:
fever, persistent cough,
jaundice, diarrhoea,
Acute Flaccid Paralysis/
vaccine preventable
diseases, unusual events
leading to death/
hospitalisation
Diagnosis is made based
on history and clinical
examination by Medical
Officers. 22 diseases and
conditions are listed under
the reporting using the
P form.
Diagnosis is based on
clinical diagnosis confirmed
by an appropriate test.
12 diseases are reported
under the L form.
Syndromic (S form) Presumptive (P form)
Laboratory/Confirmed
(L form)
3 Background, Scope and Organisation of Disease Surveillance in India
Rapid response teams will
work for 8 hours a day for
seven days a week. This is
usually a local response.
Multiple departments
will be involved and the
response will be for a
minimum of seven days,
with teams working for up
to 14 hours each day. This
includes both local, district
and state level response.
This is a 24/7 effort which
will be agency wide. This
geographically extends to
state, regional or national
level response.
Level 1 response Level 2 response Level 3 response Vision 2035: Public Health Surveillance in India: A White Paper The IDSP has successfully integrated data from the Vector Borne Disease Control Program
including data on malaria, filariasis, dengue fever, Japanese Encephalitis, chikungunya and
Kyasanur Forest Disease, among others. Other programs such as the Diarrhoeal Disease Control
Program, zoonotic infections (rabies/dog bite and snake bite), Vaccine Preventable Diseases and
Acute Respiratory Infections are also included. However, vertical programs including the National
AIDS Control Program (NACP), the recently renamed National TB Elimination Program (NTEP)
and the Reproductive and Child Health (RCH) program are not yet fully integrated into the IDSP
as the IDSP took a conscious decision to focus on ‘early warning signals’ for acute conditions,
leaving the large vertical national programs to manage their own systems of surveillance.
Surveillance activities in India are largely either event-based or indicator-based. Event-based
Surveillance is usually restricted to events of public health importance, whereas indicator-based
surveillance includes monitoring of trends, occurrence of new events or compilation and analyses
of a number of events.
A number of activities, though not directly related, also contribute to Disease Surveillance. Few
examples of these are given below.
Notification
Certain diseases are notifiable under the law. While International Health Regulations mandate the
notification of certain diseases (eg., Yellow fever), India has made notification of certain endemic
and nationally prioritised diseases mandatory, such as Tuberculosis (TB). TB is currently notified
on the Nikshay platform. Data on this platform serves as an excellent source of not only tracking
progress in detection of missing cases of TB, but is also used to track outcomes among those
treated in the public and private sector, by type of TB, by co-morbidity (HIV and diabetes) and
other factors.
Sentinel Surveillance
An example is HIV Sentinel Surveillance among antenatal women and those presenting in STI
clinics using sequential sampling during fixed periods of time from select public health facilities.
This data is used as the basis for classification of districts (Type A-D, where A has the highest
prevalence) and for defining the program response. HSS also tracks HIV trends using information
from fixed sites.
Active & Passive Surveillance
Surveillance of Malaria is both active and passive. In active surveillance, health workers visit
house-to-house enquiring about fever, collecting blood smears and administering presumptive
treatment in malaria endemic areas. Passive surveillance is conducted among those presenting to
a health facility with complaints of fever. Any fever, detected by active and passive surveillance,
in a malaria endemic area (defined as an Annual Parasite Index of >2) is presumptively treated
for malaria after a blood smear is collected for examination of malaria parasites. The program
component is restricted to passive surveillance in areas where API is < 2.
Vector Surveillance
Vector surveillance includes indicators such as vector biting rate, vector density, surveillance of
breeding sites, etc., It is used to detect outbreaks of dengue, chikungunya, malaria. Different
local and state governments have launched campaigns to examine and eliminate breeding
sites for mosquitoes, as a preventive measure for Dengue or Malaria outbreaks. While these
campaigns are themselves not considered to be surveillance activities, they are good examples
of preventive actions instituted as a result of information from surveillance that have previously
indicated seasonal trends in disease outbreaks.
Laboratory Surveillance
Apex labs, intermediate and state level laboratories have been set up for most national programs
including TB, HIV and other viral diseases to detect AMR. Pilot initiatives have successfully
50 51Vision 2035: Public Health Surveillance in India: A White Paper
demonstrated that it is feasible to diagnose a substantial proportion of Acute Febrile Illness
or Acute Encephalitis Syndromes through minimal strengthening of collection systems, referral
networks and laboratories at block or district level. AMR is a growing area of public health concern.
Sample surveys
Sample surveys have been conducted to determine risk factors for non-communicable diseases.
Sample surveys are also used to determine the prevalence of disease. An example is the recently
concluded TB prevalence survey conducted by ICMR institutes. The surveys help to estimate or
revalidate the disease burden and programmatic response.
Registries
The main source of information that is being used for estimating the burden of cancer and its
distribution are Cancer registries. These registries have been instituted in Cancer Care Centres,
including Government and a few private sector institutions. Recently, 25 Cancer Care Centres
were recognised and there has been a rapid expansion in the number of regional institutes of
cancer in the country.
Outbreak investigations
Diarrhoea, Acute Encephalitis Syndrome, Acute febrile illness are examples of syndromes wherein
outbreak investigations are conducted. Most acute conditions are reported by front-line health
workers or primary care facilities and include the reporting of diarrhoea/cholera, acute encephalitis
syndrome and acute febrile illness. Media and health authorities also routinely report outbreaks
of food poisoning or sudden increase in hospitalisation due to a certain syndrome. This serves as
an early warning signal for most outbreak investigations that are then investigated and confirmed
by a rapid response team set up at district/state level. A single case of acute flaccid paralysis was
considered to be an epidemic, under the National Polio Eradication program.
Special Studies
The Integrated Behavioural and Biological Surveys (IBBS) among at-risk populations for HIV
infection is an example of special studies contributing to surveillance of disease trends and trends
in risk behaviour.
The Organisation of Disease Surveillance in India:
Surveillance activities in India are organised at three levels: National, State and District.
CSU is integrated administratively and financially with the National Centre for Disease
Control (NCDC), New Delhi and established by the Ministry of Health and Family Welfare
for the Global Health Security Agenda (GHSA). The CSU has 14 technical centres/
divisions, including epidemiology, microbiology, zoonosis, medical entomology and vector
management, IDSP, Centre for AIDS and Related Diseases, biochemical and toxicology,
biotechnology, parasitic diseases, malariology and coordination, occupational and
environmental health, non-communicable diseases, statistics and M&E, planning, budget
and administration. The CSU runs a two-year MPH course in Field Epidemiology.
There is SSU in each State/UT with a regular officer identified as State Surveillance Officer
(SSO). The SSO is supported by 7 contractual staff who include Training manager, Finance
manager, Data manager, Epidemiologist, Microbiologist, Entomologist and a recently
included Veterinary consultant.
There is one DSU in each district with a regular officer as District Surveillance Officer (DSO),
who is supported by 3 contractual staff.
CENTRAL SURVEILLANCE UNIT (CSU)
STATE SURVEILLANCE UNIT (SSU)
DISTRICT SURVEILLANCE UNIT (DSU) 52Vision 2035: Public Health Surveillance in India: A White Paper
Data flows into the District Surveillance Units from peripheral health institutions as depicted in
Figure 11.
At the national level, the CSU coordinates with the WHO, the Indian Council of Medical Research
(ICMR), the National Institute of Communicable Diseases (NICD) and the Central Bureau of Health
Information (CBHI) as shown in Figure 12. Data pertaining to Surveillance from the national
programs including National TB Elimination Program (NTEP), National AIDS Control Organization
(NACO), Reproductive and Child Health (RCH) and National Vector Borne Disease Control
Program (NVBDCP) is to be hosted, analyzed and available for concerned stakeholders.
DSU
SSU
CSU
PHCsPvt. Practitioners
Nursing Homes
Private Hospitals
Corporate Hospitals
Other Hospitals:
ESI, Municipal
Rly., Army etc.
Programme
Officers
Sub-Centres
Private Labs
CHCs
DHs
MCs
Public Labs
Figure 11: Information Flow - Weekly Surveillance System 53Vision 2035: Public Health Surveillance in India: A White Paper
EMR
NICD
ICMRCBHI
RCHRNTCPNVBDCPNACO
CSU
National
Programs
WHO
Outbreak Investigation
& Rapid Response
Programme Monitoring
NCD SurveillanceMIS & Report
The Indian Council of Medical Research (ICMR) - Role in Surveillance:
The ICMR’s contribution in understanding various diseases of national importance such as
malaria, Japanese Encephalitis, tuberculosis, AIDS, Kala-azar, Filariasis, Leprosy and Poliomyelitis
is remarkable. Additionally, ICMR has made extensive contributions in the areas of nutrition,
reproduction and maternal and child health, occupational and environmental health with research
complementing health systems. The ICMR has a regional network of 26 institutes. They are involved
in the evaluation of new drugs, insecticides, vaccines, devices, diagnostic kits. Additionally, they
play a key role in interventions for all diseases of national health priority along with neglected
and regional diseases. ICMR has linked 106 viral research laboratories, which are used for lab
testing in epidemic outbreaks and is involved in mathematical modelling for Malaria and Dengue
in North East. Point-of-Care devices are being piloted for Leptospirosis. ICMR is also supporting
a ‘Center for One Health’ for surveillance of nosocomial infections and hospital infection control
in Nagpur, and a National Centre for Occupation Health conducts surveillance of heavy metals in
plants. This Centre has a Surveillance program for Injuries and Accidents. ICMR is working towards
developing systems for interoperability, which is expected to be finalized in about a year’s time.
During the recent outbreak, the National Institute of Virology confirmed the presence of Nipah
Virus in Kerala, India. ICMR has funded pilots and projects to demonstrate that Kala-azar (Visceral
Leishmaniasis) can be eliminated. ICMR also set up a Sentinel Surveillance for Congenital Rubella
Syndrome (CRS) in India with six sites and a hospital-based sentinel surveillance for Pneumonia
and Invasive Bacterial Diseases (IBD). The ICMR-National Institute of Cholera and Enteric Diseases
(ICMR- NICED) houses the National AMR Hub and Repository and is envisaged to carry forward
the AMR research in India from a multidimensional approach. There is potential to integrate IDSP
surveillance of bacterial infectious diseases with AMR research and translate this into a National
Programme of AMR in future.
From Old to New - From Integrated Disease Surveillance Program to Integrated Health
Information Platform:
In the traditional system of surveillance which is still operational in the majority of the states in
India, the IDSP captures aggregate data, is paper-based, is not able to link data from S, P and L
forms, delivers only weekly surveillance and monitors only 13 health conditions (Figure 13).
Figure 12: Linkages of CSU at Central Level 54Vision 2035: Public Health Surveillance in India: A White Paper
Source: Karnataka Best Practice ppt @ Gujarat Summit 2019
VILLAGE
(655075)(Auxiliary Nurse
Midwife, or Male
Health Worker)
Weekly household
visits to collect data
B-PHC or CHC data
collected from PHCs
(Medical Doctor +
helper)
(District Surveillance Officer,
Data Manager, Data Entry
Operator)
(State Surveillance Officer,
Data Manager, Data Entry
Operator)
Laboratory Presence
Laboratory Presence
Laboratory Presence
SUB-DISTRICT
(6267)
DISTRICT
(707)
STATE
(36 STATES/UTs)
Sub Center
Primary Health Center
One Consolidate “S”
form per Sub-center
per week
Paper forms
Paper forms
Spreadsheets
One Consolidate ”P”
form/PHC/week +
”L” forms
Paper forms are
coverted in to
electronic data
Electronic data, kept
in the form of XL sheets
or on a DB/Portal
Email-
Web
Entry
hand
delivered
hand
delivered
Block PHC or
Community Health Center
District Surveillance Unit
State Surveillance Unit
The new IDSP now uses the IHIP (Figure 14) to capture individualized data that can be
disaggregated by age, gender and locality, links data from Syndrome, Presumptive and Laboratory,
Early Warning Signals 1 and 2 forms, captures near real-time or daily surveillance data, provides
analysis on mobile and electronic devices and monitors more than 33+ health conditions. The IHIP
is already integrated with the NVBDCP, but full integration has not yet been achieved for the other
national programs.
The IHIP is an open platform and has the ability to connect with eHospital Systems and the new
National Health Management Information System. It can thus connect with both public and private
hospitals, laboratories, and research centers under one platform to facilitate the exchange of
health data in a secure manner. Data from the IHIP can be used to describe and analyze geographic
variations in diseases in the context of demographic, environmental, behavioural , socioeconomic,
genetic, and infectious risk factors. Data from the IHIP can also be used to explore geographic
locations of persons with their socioeconomic and demographics attributes as data captures geo-
coordinates and socio-demographic characteristics. However, the IHIP needs further refinement
to:
1. Integrate Communicable disease with NCDs as comorbidity using unique patient identifier.
2. Capture complications and proportions with severe disease as this is useful to decide on
appropriate action. For eg., Proportion with severe dengue fever, staging for cancer.
3. Integrate prevention (vaccine/chemoprophylaxis) and treatment data.
4. Integrate other types of data such as immunization coverage, AMR, nutrition status, vector
indices, climatic factors, health system availability.
5. Capture the entire continuum in care including outcomes such as death, cure/recovery/
completed treatment, relapse/recurrence, number of episodes, etc. for enhanced understanding
of disease spectrum/prognosis and health resource planning.
Figure 13: Conventional IDSP’s Data Collection Process 55Vision 2035: Public Health Surveillance in India: A White Paper
HIV Surveillance:
HIV Sentinel Surveillance (HSS) was perhaps one of the first nation-wide surveillance systems
that initially helped to confirm the presence of HIV in India through sentinel sites and designated
laboratories beginning in 1992. By 1997, HSS expanded to both antenatal and high-risk
populations which provided critical insights on the geographic distribution of the HIV epidemic
within India. The HSS thus helped to identify six states with high prevalence. In 2003, HSS
expanded to cover every district in all high prevalence states and to have a state representative
sample for regions that were not yet declared to be high HIV prevalent. In 2006, the National
Family Health Survey (NFHS) 3 for the first time integrated HIV prevalence among the indicators
that were measured. About a decade later, the National AIDS Control Organisation (NACO)
instituted Integrated Behavioural and Biological Surveillance (IBBS) which enabled tracking of not
only the disease prevalence and distribution, but also helped to understand the risk factors that
were determinants and drivers of the epidemic across geographies and sub-population groups.
HIV surveillance thus provides useful information to estimate the burden of HIV, the distribution
by population and place, and trends over time. Additionally, program data has been useful in
estimating the new infections and their distribution, and in estimating over time, the reduction in
death rates among those on treatment.
Polio surveillance in India:
India’s Acute Flaccid Paralysis (AFP) surveillance system for detecting poliovirus transmission was
considered to be one of the most sensitive surveillance systems in the world. The surveillance
network was widespread. It included both public and private sector reporting sites. It even
included non-allopathic healthcare providers and traditional healers. These sites would give a
call on mobile phone to a designated district surveillance/ immunization officer whenever a case
of AFP was detected. The district immunization officer would then ensure sample collection
for laboratory diagnosis. India both met and surpassed all of the WHO AFP Surveillance
Source: Karnataka Best Practice ppt @ Gujarat Summit 2019
VILLAGE
(655075)
Mobile reporting
Portal access
Mobile reporting
Portal access
Mobile Reporting
Portal access
Mobile Reporting
Proposed System: Portal access allows reporting of all data from DSU, CSU, SSU to CSU/IDSP in near real-time.
Mobile reporting is both store and forward and near real-time. Data analytics and results will be accessible at all
levels for action.
Sub Center or
Health Sub Center
Primary Health Center
Block PHC or
Community Health Center
Broadband Connectivity
Data Entry
Computer
Data
Entry
Comp.
Data
Entry
Comp.
Data
Entry
Comp.
Data
Center
Broadband Connectivity
Broadband and Satellite-based
Connectivity
District Surveillance
Unit
State Surveillance
Unit
SUB-DISTRICT
(6267)
DISTRICT
(707)
STATE
(36 STATES/UTs)
Laboratory Presence
Laboratory Presence
Laboratory Presence
Figure 14: New IHIP Real-Time Data Flow Processes 56Vision 2035: Public Health Surveillance in India: A White Paper
global performance indicators over 10 years. Following this, India was certified polio free. The
development of surveillance performance indicators is unique to AFP surveillance for Polio and
is an innovation worth applying to other diseases/health conditions of public health importance.
India’s AFP surveillance system provides evidence of operational feasibility for polio surveillance.
It also provides a road map for global quality surveillance in low and middle income countries.
System for Early Warning Based on Emergency Data (SEED):
SEED was a collaborative project of the GVK Emergency Management and Research Institute
(EMRI), India, and GEOMED Research, Germany to systemically explore the use of emergency
data for syndromic surveillance at the primary care level in Andhra Pradesh. The project is a
combination of a database and corresponding algorithm and GIS tools. EMS (emergency
management system) data are generated and captured automatically at the state dispatch centre
in Hyderabad. It serves as an early warning system for disease outbreaks through automatic
comparison of real time data and pre-determined thresholds. The EMS data are generated and
captured in 15 states and 2 union territories.
National Health Policy and Public Health Surveillance:
The National Health Policy 2017 clearly articulated that India needs to accelerate progress in order
to achieve the Millennium Development Goals by 2015 and the Sustainable Development Goals
by 2030. In alignment with the Universal Health Coverage objective and its guiding principles
of ensuring universal health as a right and entitlement, guaranteed access to an essential health
package including primary, secondary and tertiary care and freedom of choice for patients
between the public and private sector, ensuring equity, non-exclusion and non-discrimination,
comprehensive quality care, financial protection, and protection of patient’s rights and respect
for patient’s choice, portability and continuity of care, community participation and putting health
in people’s hand, the plan also set ambitious targets. Prominent among these targets was an
increased allocation of GDP for health from its existing level to 2.5% by the end of the plan
and to 3% by 2022, ensuring availability of free medicines and reducing out-of-pocket services.
The policy stated that 70% of all health care resources would be dedicated towards improving
primary health care. Convergence of all vertical disease control programs under the umbrella of
the National Health Mission, the integration of the delivery of all health services, universal and
cashless access to an essential health package including essential medicines is stressed. A Health
information system that captures both population, community and facility based information,
linking all providers, laboratories, and public health managers, so that it is able to provide
information to monitor disease burden and support decision making and resource allocation was
laid out as a priority. Public health surveillance, research and control of risks and threats to public
health are prominently included in the essential health package. 57Vision 2035: Public Health Surveillance in India: A White Paper
1. Thacker S B, Berkelman R L. Public Health Surveillance in the United States. Epidemiologic
Reviews.1988.DOI:10.1093/oxfordjournals.epirev.a036021
2. WHO.STEPwise approach for NCD surveillance.2003
3. DGHS/MoHFW. IDSP Medical Officer Manual.2005
4. WHO. Communicable Disease Surveillance and Response systems – a guide to monitoring
and evaluating.2006
5. Barker I, Brownie J, et al. Foresight. Infectious Diseases: preparing for the future: A Vision of
Future Detection, Identification and Monitoring Systems. Office of Science and Innovation,
London.2006
6. Lee L M, Thacker. Principles and Practice of Public Health Surveillance.2010
7. Balabanova Y, Gilsdorf A, Buda S, et al. Communicable Diseases Prioritized for Surveillance
and Epidemiological Research: Results of a Standardized Prioritization Procedure in Germany.
PlOS One. October 2011
8. Bernard C K Choi. The Past, Present and Future of Public Health Surveillance. Hindawi
Scientifica. page 26.2012. DOI 10.6064/2012/875253
9. Thacker S B, Qualters J R, Lee L M…Public health surveillance in the United States: evolution
and challenges. MMWR Weekly Report.CDC.2012
10. Washington R G. Integrated Vector Control Measures in Managing Vector Borne Diseases.
Cover Story. Health Action.2012
11. Department of Health, PHE Transition Team. Towards a Public Health Surveillance Strategy
for England.2012
12. Planning Commission, GoI.12th five-year plan-faster, more inclusive and sustainable growth
– volume 1.2013
13. WHO. Global Action Plan for prevention and control of NCD 2013-2020.2013
14. Gururaj G. Growing burden and impact of road crashes in India – need for safe systems
approach. International J of Vehicle Safety. Vol 7.2014.
15. DGHS. Joint Monitoring Mission Report.2015
16. Phalkey R K, Yamamoto S, Awate P, Marx M. Challenges with the implementation of an
Integrated Disease Surveillance and response System: systematic review of the lessons
learned. Health Policy and Planning.2015 Feb;30(1):131-43. DOI: 10.1093/heapol/czt097.
Epub 2013 Dec 20. PMID: 24362642
17. Krafft T, Pilot E, Sarkar B K, Ryland P, Reeves L, Singh V. Research and Innovations guiding
Public Health Surveillance in the Twenty-first century. Book. Transforming Public Health
Surveillance Elsevier. Chapter 30.2016.
18. Pan Canadian Public Health Network. Blueprint for a Federated System for Public Health
Surveillance in Canada: Vision and Action Plan.Ottawa.2016
19. Ministry of Health and Family Welfare. GOI. National Health Policy 2017. https://www.nhp.
gov.in/nhpfiles/national_health_policy_2017.pdf
20. NCDC, DGHS. Training manual for medical officers for prevention, control and population
level screening of hypertension, diabetes and common cancers.2017
21. CDC. Power-point document Enhancing Real-time Sentinel Infectious Disease Surveillance in
India: Background information for Preparation of State PIP.2017.
22. Pilot E, Roa R, Jena B, et al. Towards Sustainable Public Health Surveillance in India: Using
Routinely Collected Electronic Emergency Medical Service Data for Early Warning of Infectious
Diseases. Sustainability. MDPI. 2017.DOI:10.3390/su9040604
23. Jian S W, Chen C M, Lee C Y, Liu D P. Real-Time Surveillance of Infectious Diseases: Taiwan’s
Experience. Health Secur. 017;15(2):144–153.DOI:10.1089/hs.2016.0107
24. NACO.HIV Sentinel Surveillance, Technical Brief – 2017.December 2017
25. Martin D, Miller A P, et al. Canada’s universal health-care system: achieving its potential.
Lancet series.2018.DOI:10.1016/S0140-6736(18)30181-8
4 Bibliography 58Vision 2035: Public Health Surveillance in India: A White Paper
26. NHSRC. Ayushman Bharat: Comprehensive Primary Health Care through Health and Wellness
Centres – Operational Guidelines.2018
27. Bhatia R, Katoch V M, Inoue H. Creating political commitment for antimicrobial resistance in
developing countries. Indian J Med Res 149, February. 2019.DOI: 10.4103/ijmr.IJMR_1980_17
28. Taweewigyakarn P. Public Health Surveillance. Thailand: power-point document accessed
from http://www.interfetpthailand.net/
29. NCDC, IHIP manuals. User Manual, S form, P form, L form, Event outbreak manual, Media
scanning and verification cell manual, Revised Guidelines for the collection, storage and
transportation of samples for the diagnosis of Influenza, Office Note: Revised TA/DA guidelines
for training, Weekly report 34, 39, Monthly report April 2019.June 2019
30. NITI Aayog. National Digital Health Blueprint. July 2019
31. NITI Aayog. India Health Sector Risk Pooling – Challenges, Opportunities and Options for
Improvement. 2019
32. NITI Aayog. Healthy States: Progressive India: Health Index. June 2019
33. https://www.cdc.gov/mmwr/index.html
34. https://www.promedmail.org/index.php
35. https://www.canada.ca/en/public-health/services/surveillance.html
36. NITI Aayog. Internal notes on visit of Mr Alok Kumar to Public Health Agency Canada.2019.
37. Krishnamurthy J, et al. Designing a comprehensive NCD program for hypertension and
diabetes at the primary care level: evidence and experience from urban Karnataka, S India.
BMC Public Health.2019
38. WHO, FAO, others. Enhancing progress towards Rabies Elimination by 2030 in SAARC
countries – workshop report. June 2019
39. USAID. Community event based surveillance of priority human and zoonotic diseases in
Senegal. Measuer Evaluation. September 2019
40. Sinclair A J. Sub-sahara Africa – The impact and challenge of type 2 diabetes mellitus requiring
urgent and sustainable public health measures. Eclinical Medicine. ScienceDirect, October
2019. DOI: 10.1016/j.eclinm.2019.10.005
41. WHO. Short Note on IDSP.November2019
42. WHO.IHIP presentation from Karnataka at National Summit, Gujarat. November 2019
43. IDSP.nic.in: last accessed on November 25, 2019
44. Eclinical Medicine. Editorial on Leprosy – forgotten not gone. ScienceDirect. October 2019
45. Wagstaff A, Neelsen S.A comprehensive assessment of UHC in 111 countries: a retrospective
observational study. Lancet GlobHealth. December.2019. DOI: 10.1111/j.1365-4632.2011.
04961.x
46. Fullman N., Lozano R. Measurement matters: who and what counts on the road to UHC.
Lancet GlobHealth.December.2019.DOI:10.1016/S2214-109X(19)30499-1
47. Sudarshan M K, Narayana D H A. Appraisal of Surveillance in Human Rabies and Animal Bites
in Seven States of India. IJPH, December 2019. DOI: 10.4103/ijph.IJPH_377_19
48. Centrient Pharmaceuticals. Letter of request to include AMR in the Vision 2035 document on
Surveillance. January 2020
49. Sarin S.Note on IDSP and Essential Diagnostics List. January 2020
50. WHO. Overview of Ending Cholera – A Global Roadmap to 2030.January 2020.
51. Bhatia R. Need for integrated surveillance at human-animal interface for rapid detection and
response to emerging coronavirus infections using One Health approach. Perspective. Indian
J or Med Res 151.February 2020. DOI: 10.4103/ijmr.IJMR_623_20
52. Bhatia R, Abraham P. Time to revisit national response to pandemics. Indian J of Medical Res
151, pp111-113.February-March 2020. DOI: 10.4103/ijmr.IJMR_846_20 59 Health vertical
National Institute for Transforming India
NITI Bhawan, Sansad Marg
New Delhi – 110001
healthdiv-pc@gov.in
011 - 23042547
ISBN 978-81-949510-6-3
DOI: 10.6084/m9.figshare.14093323
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER 2Vision 2035: Public Health Surveillance in India: A White Paper
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER
Vision 2035: Public Health Surveillance in India
A White Paper
Publishing Agency: NITI Aayog
Year of Publication: 2020
Book, English
ISBN 978-81-949510-6-3
DOI: 10.6084/m9.figshare.14093323
Suggested Citation: Blanchard J; Washington R; Becker M;
Vasanthakumar N; Madangopal K; Sarwal R. et al. Vision 2035: Public
Health Surveillance in India. A White Paper. NITI Aayog. December 2020. 1Vision 2035: Public Health Surveillance in India: A White Paper
VISION 2 035
PUBLIC HEA LTH
SURVEILLANCE IN INDIA
A WHITE PAPER Vision 2035: Public Health Surveillance in India: A White Paper ii
Foreword ................................................................................................................................................................................
Preface .....................................................................................................................................................................................
Message .................................................................................................................................................................................
Acknowledgements .....................................................................................................................................................
List of Contributors ......................................................................................................................................................
Abbreviations ....................................................................................................................................................................
Executive Summary .....................................................................................................................................................
1. Scope of the Document .................................................................................................................................
2. Vision 2035: Public Health Surveillance in India ..................................................................
2.1 Vision ........................................................................................................................................................................
3. Background and Introduction .................................................................................................................
3.1 Definitions ............................................................................................................................................................
3.2 Progress .................................................................................................................................................................
3.3 Opportunities ....................................................................................................................................................
3.4 Threats .....................................................................................................................................................................
3.5 Challenges in India’s current Public Health Surveillance ........................................
4. Key Considerations in Creating Vision 2035 ..........................................................................
5. The Building Blocks for Vision 2035: Public Health Surveillance in India ....
5.1 Governance: Principle: Develop an eco-system for surveillance ....................
5.2 Information Systems linked with robust lab networks as data sources
for Surveillance .........................................................................................................................................................
5.3 Data Analytics (including Predictive Analytics) ................................................................
5.4 Information for Action: Principle: ‘For Public good’ ..................................................
6. Steps towards achieving Vision 2035: Public Health Surveillance in India .....
6.1 Raise the profile of Public Health Surveillance ................................................................
6.2 Create/Strengthen an Independent Health Informatics Institute ..................
6.3 Define the scope of surveillance into broad categories of diseases/
conditions, keep it simple and strategic ..........................................................................................
6.4 Use a WHO STEPwise approach to include NCD Surveillance .......................
6.5 Prioritise Diseases/Conditions that will be the focus for Surveillance/
Disease Elimination ...............................................................................................................................................
6.6 Improve Core Support Functions, Core Functions and System
Attributes........................................................................................................................................................................
6.7 Streamline data sharing, analysis, dissemination and use for action .........
iv
v
vi
vii
viii
x
xii
1
3
4
5
6
6
8
10
12
17
21
22
23
24
25
27
28
29
29
29
30
30
30
TABLE OF CONTENTS Vision 2035: Public Health Surveillance in India: A White Paper iii
31
31
32
35
37
38
39
40
40
41
22
26
28
33
43
44
45
45
46
47
48
52
53
54
55
49
57
6.8 Encourage Innovations ............................................................................................................................
6.9 Align with Ayushman Bharat .............................................................................................................
6.10 Strengthen laboratory infrastructure, referral networks and
community based surveillance ..................................................................................................................
7. Conclusion ....................................................................................................................................................................
Annexures ............................................................................................................................................................................
1. List of Tables
Table 1: WHO list of Diseases slated for Elimination and their Timelines .......
Table 2: Diseases under Integrated Disease Surveillance Program ......................
Table 3a: The WHO STEPwise approach to NCD surveillance ..................................
Table 3b: STEPS approach to risk factor assessment ..........................................................
Table 4: Criteria for scoring to Prioritise diseases/conditions for
Surveillance ..................................................................................................................................................................
2. List of Figures
Figure 1: The Architecture of Public Health Surveillance in 2035 ...........................
Figure 2: The Proposed Flow of Information for Public Health Surveillance
in 2035 ...............................................................................................................................................................................
Figure 3: The Way Forward: Public Health Surveillance in India ..............................
Figure 4: Integration of PHS into Ayushman Bharat ............................................................
Figure 5: Existing Structure for Public Health Surveillance ...........................................
Figure 6: Improved Health Systems Support, Core Functions & System
Attributes .......................................................................................................................................................................
Figure 7a: Examples of Key Building Blocks for Surveillance ......................................
Figure 7b: Key Building Blocks for Vision 2035: PHS in India .....................................
Figure 8: The Public Health Surveillance Loop ..........................................................................
Figure 9: Framework for Future Detection, Identification and Monitoring
Systems ............................................................................................................................................................................
Figure 10: Real-Time Surveillance of Infectious Diseases in Taiwan .....................
Figure 11: Information Flow - Weekly Surveillance System ..........................................
Figure 12: Linkages of CSU at Central Level ...............................................................................
Figure 13: Conventional IDSP’s Data Collection Process ................................................
Figure 14: New IHIP Real-Time Data Flow Processes .........................................................
3. Background, Scope and Organisation of Disease Surveillance in India ....
4. Bibliography ................................................................................................................................................................ Vision 2035: Public Health Surveillance in India: A White Paper iv
FOREWORD
India has made substantial progress in the prevention, control, and elimination of
major communicable diseases. Smallpox was eradicated worldwide and Polio has been
eliminated in India. India has substantially reduced the incidence of HIV infections by
more than half in the last two decades. Recent outbreaks including the COVID-19 and
Nipah virus have been effectively contained or controlled.
None of these initiatives would have been possible without strong Public Health
Surveillance systems in place. The time is right to enhance the surveillance of non-
communicable diseases and to replace traditional surveillance systems of data-entry with
recent developments in digital health and technology, in alignment with the National
Digital Health Mission. Further, building on the 2017 National Health Policy’s directions
for enhanced surveillance, it is important to enhance citizen-centricity into public health
surveillance and services. As well, the Health and Wellness Centers established under the
Ayushman Bharat provide a platform to enhance community-based surveillance for both
infectious and non-communicable diseases.
The COVID-19 pandemic has provided us with an opportunity to revisit (re) emerging
diseases due to increased interaction between human-animal-environment. Early
identification of this interface is essential to break the chain of transmission and to create
a resilient surveillance system. This vision document on Public Health Surveillance in India
by 2035 is a step in this direction. It articulates the vision and describes building blocks.
It envisions integration, enhanced citizen-centric and community-based surveillance,
strengthened laboratory capacity, expanded referral networks, and a unified Surveillance
Information Platform that will provide data for decision making and action.
I congratulate the NITI Health vertical for bringing out this document, in consultation
with national and global level experts. Vision 2035: Public Health Surveillance in India: A White Paper v
PREFACE
The National Institute for Transforming India (NITI Aayog) functions as a think tank and
resource centre or knowledge hub, fosters cooperative federalism, designs policy and
program framework and guides monitoring and evaluation of National Programs in India.
In alignment with the Universal Health Coverage focus towards achieving the Sustainable
Development Goals by 2030, NITI has focused on holistically transforming the delivery
of health care services across the public and private sectors. Multiple stakeholder
consultations were conducted to identify the priorities for core building blocks of a
Health System for New India.
Enhancing Public Health Surveillance is an important public health function. This includes
the detection of disease and early warning signs of impending outbreaks or epidemics,
both those endemic to the country or those that constitute a public health emergency
of international concern. Tracking acute and chronic disease trends and responding with
timely and effective actions are critical functions of surveillance.
This paper is a vision for Public Health Surveillance in India in 2035, written by national
and global experts in the field of public health surveillance. The document becomes even
more relevant as India and the world tackles the pandemic of COVID-19. The gains made
and lessons learned from COVID-19 and past experience with identifying and controlling
outbreaks, reducing, eliminating and eradicating diseases must be consolidated to
enhance Public Health Surveillance in India. In the spirit of Cooperative Federalism, we
look forward to make this vision a reality and to thus ensure India’s leadership in disease
prevention and response at a global level.
Dr. Vinod. K. Paul,
Member, NITI Aayog vi
MESSAGE
The NITI Aayog was established in 2015 by the Government of India as a policy think
tank. Its aim is to achieve Sustainable Development Goals through cooperative federalism,
fostering the involvement of State Governments and using a bottoms-up approach.
Recently launched initiatives of the Government of India provide an opportunity to re-look
at Public Health Surveillance. The flagship Ayushman Bharat program that is focused on
enhancing the provision of comprehensive primary health care through Health and Wellness
Centres and on reducing catastrophic out-of-pocket expenditure among poor and middle-
class families through the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY)
insurance scheme are opportunities to enhance public health surveillance. The more recent
launch of the Prime Minister’s Atma Nirbhar Swasthya Bharat Yojana (PMASBY) focuses
on making India self-reliant. Under this program, plans are afoot to enhance laboratory
infrastructure and health systems at the block level in order to prepare and respond in a
timely manner to future pandemics.
Surveillance is ‘Information for Action’. Public health surveillance, an important public
health function, cuts across primary, secondary and tertiary levels of health care. Beyond
improving existing isolated systems, the integrated solution envisioned in this document
encompasses a ‘One-Health’ approach that amalgamates health information from different
sources including human, plant and animal surveillance. A unitised and unified real-time
surveillance that is not based on traditional systems of data entry and upload, but one that
allows interoperability and data sharing mechanisms, capitalising on technological and
digital advances are in alignment with the National Digital Health Mission.
The vision suggests the utilisation of new situation-aware real-time signals from social media,
mobile/sensor networks and citizens’ participatory surveillance systems for event based
epidemic intelligence in addition to the existing systems and electronic health records
for case-based surveillance linked through the optimal use of unique health identifier.
Finally, the vision highlights the effective support coordination of multidisciplinary teams,
risk communication with citizens as the primary stakeholders and the implementation of
prevention measures at all levels for a timely and effective public health response. We
must not lose the opportunity that the COVID-19 pandemic has provided us. We must
strengthen our health systems and services and public health surveillance mechanisms.
The vision document provides insights and ideas for India to move ahead in this direction.
Amitabh Kant,
Chief Executive Officer, NITI Aayog
Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper Traditional public health disease surveillance systems in India have remained fragmented,
siloed, and limited to few diseases. As India re-imagines and reforms its health systems,
we need to ensure that our Public Health Surveillance systems are also made citizen-
centric and within the context of the overall socio-economic development of the country.
In 2020, the NITI Aayog signed a Letter of Agreement with the University of Manitoba,
Winnipeg, Canada to develop a white paper on a Vision for Public Health Surveillance in
India by 2035.
This vision document on Public Health Surveillance in India-2035, which takes forward the
vision as envisaged in the National Health Policy 2017, lays the foundation for integrated
surveillance of both communicable and non-communicable diseases.
This document identifies four building blocks for this vision. These include a) an
interdependent federated system of Governance architecture between the Centre and
States; b) new data collection and sharing mechanisms for surveillance based on unitized,
citizen-centric comprehensive Electronic Health Records with a unique health identifier,
amalgamating existing disease surveillance programs, complemented by information
from periodic surveys; c) enhanced use of new data analytics, data science, artificial
intelligence and machine learning; and d) advanced health informatics.
We hope that this document will pave the road towards collectively propelling India to
be a regional and global leader with ‘Information for Action’, in consideration of the
overarching principle ‘for the public good’.
We thank the Institute of Global Public Health at the University of Manitoba and the
national and global experts who have compiled this vision document. We would like
to acknowledge the various contributors listed for their unstinted commitment and
dedication to this exercise.
We are grateful to Dr. Rajiv Kumar, Vice Chairman, Dr. Vinod K Paul, Member, and
Shri Amitabh Kant, CEO NITI Aayog, for their constant inspiration and guidance that made
this document possible, and the health division team Shri Alok Kumar, Former Advisor,
and Dr. K Madan Gopal, Senior Consultant for having contributed to this exercise.
Dr. Rakesh Sarwal
Additional Secretary, NITI Aayog
Vision 2035: Public Health Surveillance in India: A White Paper
ACKNOWLEDGEMENTS
vii Vision 2035: Public Health Surveillance in India: A White Paper LIST OF CONTRIBUTORS
No.
1
2
3
4
5
6
7
8
9
1
2
3
4
Professor/Director
Associate Professor
Associate Professor
Executive Director: Uttar Pradesh
Technical Support Unit (UPTSU)
Assistant Professor
Director: UPTSU
Program Specialist
Director: UPTSU
Deputy Director: UPTSU
Additional Secretary
Former Advisor
Principal Secretary Health
Senior Consultant (Health)
Officer on Special Duty (OSD)
University of Manitoba/Institute
of Global Public Health
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
University of Manitoba
NITI Aayog
NITI Aayog
Government of Uttar Pradesh
NITI Aayog
NITI Aayog
NameDesignationOrganization
Vision 2035: Public Health Surveillance in India: A White Paper
James Blanchard
Reynold Washington
Marissa Becker
Vasanthakumar N
Shajy Isac
Sameer Kanwar
Antony Joseph
Bidyut Sarkar
Sushant Jain
Rakesh Sarwal
Alok Kumar
K Madan Gopal
K Venkatanarayan
AUTHORS
NITI AAYOG
viii Vision 2035: Public Health Surveillance in India: A White Paper 1
2
3
4
5
6
7
8
,
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Gangakhedkar R
Himanshu Chauhan
Kamlesh Sarkar
Kayla Laserson
Manoj V Muhrekar
M. K. Sudarshan
Nivedita Gupta
Pavana Murthy
Priya Abraham
Rajeev Sadanandan
Rajesh Bhatia
Rosanna Peeling
Samiran Panda
Sanjay Mehendale
Sanjay Sarin
Sanjay Tyagi
Sanket Vasant
Kulkarni
Shanta Dutta
Sujeet Kumar Singh
Suman Sharma
Suresh Mohammed
Swasticharan L
Tripurari Kumar
Head, Epidemiology &
Communicable Diseases
Joint Director & In-charge
IDSP
Director
Deputy Director,
Infectious Diseases
Director
Professor & Head
Scientist F, Epidemiology &
Communicable Diseases
Infectious Diseases
Surveillance
Director
Chief Executive Officer
Former Director,
Communicable Diseases
Professor and Chair,
Diagnostics Research
Director
Former Director, NIE
Former Director, ICMR
Country Director
Director General
Deputy Director
Director
Director
Senior Health Specialist
Chief Medical Officer
Epidemiologist & EIS
Officer-India
Indian Council for Medical Research (ICMR),
New Delhi
National Centre for Diseases Control (NCDC),
New Delhi
National Institute of Occupational Health,
Ahmedabad
India Country Office; Bill & Melinda Gates
Foundation, New Delhi
National Institute of Epidemiology, Chennai
Rajiv Gandhi Institute of Public Health,
RGUHS, Bengaluru
Indian Council of Medical Research (ICMR),
New Delhi
World Health Organization (WHO), New Delhi
National Institute of Virology, Pune
Health Systems Transformation Platform
(HSTP), New Delhi
World Health Organization (WHO)
South East Asia Regional Office (SEARO),
New Delhi
London School of Hygiene and Tropical
Medicine (LSHTM), England
National AIDS Research Institute, Pune
National Institute of Epidemiology, Chennai,
Indian Council of Medical Research, New Delhi
Foundation for Innovative New Diagnostics
(FIND), New Delhi
Directorate General of Health Services (DGHS),
New Delhi
National Centre for Disease Control, New Delhi
National Institute for Cholera and Enteric
Diseases (NICED), Kolkata
National Centre for Disease Control, New Delhi
Individual Capacity
World Bank, New Delhi
Director General of Health Services, New Delhi
South Delhi Municipal Corporation, New Delhi
No.NameDesignationOrganization
EXPERTS WHO CONTRIBUTED
Vision 2035: Public Health Surveillance in India: A White Paperix Vision 2035: Public Health Surveillance in India: A White Paper ABBREVIATIONS
AES
AFI
AFP
AIDS
AMR
API
API
CBHI
CDC
CHC
CRS
CSU
CTD
DGHS
DH
DHF/DSS
DIM
DSO
DSU
EDL
EHR/EMR
EMS
ESIC
GoI
GHSA
HIV
HR
HSS
HWC
IBBS
IBD
ICMR
IDSP
IDSR
IHIP
IoT
JE
Acute Encephalitis Syndrome
Acute Febrile Illness
Acute Flaccid Paralysis
Acquired Immunodeficiency Syndrome
Anti-microbial Resistance
Application Programming Interface
Annual Parasite Index
Central Bureau of Health Intelligence
Centre for Disease Control
Community Health Centre
Congenital Rubella Syndrome
Central Surveillance Unit
Central TB Division
Directorate General of Health Services
District Hospital
Dengue Haemorrhagic Fever, Dengue Shock Syndrome
Detection, Identification, Monitoring
District Surveillance Officer
District Surveillance Unit
Essential Diagnostics List
Electronic Health Record/Electronic Medical Record
Emergency Management System
Employees State Insurance Corporation
Government of India
Global Health Security Agenda
Human Immunodeficiency Virus
Human Resources
HIV Sentinel Surveillance
Health and Wellness Centre
Integrated Behavioural and Biological Surveillance
Invasive Bacterial Diseases
Indian Council for Medical Research
Integrated Disease Surveillance Program
Integrated Disease Surveillance and Response
Integrated Health Information Platform
Internet of Things
Japanese Encephalitis
Vision 2035: Public Health Surveillance in India: A White Paperx Vision 2035: Public Health Surveillance in India: A White Paper MC
MDR-TB
MNCH
MPH-EIS
NAAC
NACO
NAP
NARI
NCD
NCDC
NEDL
NFHS
NHM
NICD
NICED
NIOH
NITI Aayog
NTEP
NVBDCP
OTP
PHC
PHS
PMJAY
PoC
PROMED
RCH
RNTCP
SARS
SEED
SSO
SSU
STI
TB
UHID
VRDL
WHO
Medical College
Multi-drug resistant TB
Maternal, Newborn and Child Health
Masters in Public Health, Epidemic Intelligence Service
National Apical Advisory Committee
National AIDS Control Organisation
National Action Plan
National AIDS Research Institute
Non-communicable Diseases
National Centre for Disease Control
National Essential Drugs List
National Family Health Survey
National Health Mission
National Institute of Communicable Diseases
National Institute for Cholera and Enteric Diseases
National Institute for Occupational Health
National Institute for Transforming India
National TB Elimination Program
National Vector Borne Disease Control Program
One-time password
Primary Health Centre
Public Health Surveillance
Pradhan Mantri Jan Arogya Yojana
Point-of-Care
Program for Monitoring Emerging Diseases
Reproductive and Child Health
Revised National TB Control Program
Severe Acute Respiratory Syndrome
System for Early Warning Based on Emergency Data
State Surveillance Officer
State Surveillance Unit
Sexually Transmitted Infection
Tuberculosis
Unique Health Identifier
Viral Research and Diagnostic Laboratories
World Health Organization
Vision 2035: Public Health Surveillance in India: A White Paperxi Vision 2035: Public Health Surveillance in India: A White Paper EXECUTIVE SUMMARY
Vision 2035: Public Health Surveillance in India
NITI Aayog’s mandate is to provide strategic directions to the various sectors of the
Indian economy. In line with this mandate, the Health Vertical released a set of four
working papers compiled in a volume entitled ‘Health Systems for New India: Building
Blocks – Potential Pathways to Reform’ during November 2019.
“India’s Public Health Surveillance by 2035” is a continuation of the work on Health
Systems Strengthening. It contributes by suggesting mainstreaming of surveillance by
making individual electronic health records the basis for surveillance.
Public Health Surveillance (PHS) cuts across primary, secondary, and tertiary levels of care.
Surveillance is an important Public Health function. It is an essential action for disease
detection, prevention, and control. Surveillance is ‘Information for Action’.
This paper is a joint effort of the Health vertical, NITI Aayog, and the Institute for Global
Public Health, University of Manitoba, Canada, with contributions from technical experts
from the Government of India, States, and International agencies.
In 2035,
• India’s Public Health Surveillance will be a predictive, responsive, integrated, and tiered
system of disease and health surveillance that is inclusive of Prioritised, emerging, and
re-emerging communicable and non-communicable diseases and conditions.
• Surveillance will be primarily based on de-identified (anonymised) individual-level patient
information that emanates from health care facilities, laboratories, and other sources.
• Public Health Surveillance will be governed by an adequately resourced effective
administrative and technical structure and will ensure that it serves the public good.
• India will provide regional and global leadership in managing events that constitute a
Public Health Emergency of International Concern.
Multiple disease outbreaks have prompted India to proactively respond with prevention
and control measures. These actions are based on information from public health
surveillance. India was able to achieve many successes in the past. Smallpox was eradicated
and polio was eliminated. India has been able to reduce HIV incidence and deaths and
advance and accelerate TB elimination efforts. Many outbreaks of vector-borne diseases,
acute encephalitis syndromes, acute febrile illnesses, diarrhoeal and respiratory diseases
have been promptly detected, identified and managed. These successes are a result
of effective community-based, facility-based, and health system-based surveillance. The
program response involved multiple sectors, including public and private health care
systems and civil society.
Vision 2035: Public Health Surveillance in India: A White Paperxii Vision 2035: Public Health Surveillance in India: A White Paper The COVID-19 pandemic has further challenged the country. India rapidly ramped up
its diagnostic capabilities and aligned its digital technology expertise. This ensured that
there was a comprehensive tracking of the pandemic. As well, relevant information was
widely shared with the public. India rapidly instituted both case-based (Trace, Test, Treat)
and population-based measures (wear masks, wash hands, maintain distance, avoid
crowding and closed spaces) for COVID-19 prevention, management, containment, and
control. This vision document describes what India’s Public Health Surveillance can be in
2035.
This vision document on India’s Public Health Surveillance by 2035 builds on opportunities
that include the Ayushman Bharat scheme that establishes health and wellness centers
at the community level- to strengthen non-communicable disease prevention, detection,
and control and assures government payment for hospitalisation- to reduce out-of-pocket
expenses of individuals and families at the bottom of the pyramid.
• It builds on initiatives such as the IHIP of the Integrated Disease Surveillance Program.
• It aligns with the citizen-centricity highlighted in the National Health Policy 2017 and
the National Digital Health Blueprint. It encourages the use of mobile and digital
platforms and Point-of-Care devices and diagnostics for amalgamation of data capture
and analyses.
• It highlights the importance of capitalizing on initiatives such as the Clinical
Establishments Act to enhance private sector involvement in surveillance.
• It points out the importance of a cohesive and coordinated effort of apex institutions
including the National Centre for Disease Control, the Indian Council of Medical
Research, and others. As well, there may be a need to create an independent Institute
of Health Informatics.
The document identifies gap areas in India’s Public Health Surveillance that could be
addressed.
• India can create a skilled and strong health workforce dedicated to surveillance activities.
• Non-communicable disease, reproductive and child health, occupational and
environmental health and injury could be integrated into public health surveillance.
• Morbidity data from health information systems could be merged with mortality data
from vital statistics registration.
• An amalgamation of plant, animal, and environmental surveillance in a One-Health
approach that also includes surveillance for anti-microbial resistance and predictive
capability for pandemics is an element suggested within this vision document.
• Public Health Surveillance could be integrated within India’s three-tiered health system.
• Citizen-centric and community-based surveillance, and use of Point-of-Care devices
and self-care diagnostics could be enhanced.
• Laboratory capacity could be strengthened with new diagnostic technologies including
molecular diagnostics, genotyping and phenotyping. To establish linkages across the
three-tiered health system, referral networks could be expanded for diagnoses and
care.
Vision 2035: Public Health Surveillance in India: A White Paperxiii Vision 2035: Public Health Surveillance in India: A White Paper xiv
1. Establish a governance framework that is inclusive of political, policy, technical, and
managerial leadership at the national and state level.
2. Identify broad disease categories that will be included under Public Health Surveillance.
3. Enhance surveillance of non-communicable diseases and conditions in a step-wise
manner.
4. Prioritise diseases that can be targeted for elimination as a public health problem, on
a regular basis.
5. Improve core support functions, core functions, and system attributes for surveillance
at all levels - national, state, district, and block.
6. Establish mechanisms to streamline data sharing, capture, analysis, and dissemination
for action. These could include the use of situation-aware real-time signals from social
media, mobile sensor networks and participatory surveillance systems for event-
based epidemic intelligence.
7. Encourage innovations at every step in surveillance activity.
All through this process, consider strengthening human resource capacity, laboratory
infrastructure, referral networks, and community-based surveillance. Implementation of
this vision can thrust India to be a global/regional leader in Public Health Surveillance -
‘Information for Action’.
Four building blocks are envisaged for this vision:
1. An interdependent federated system of Governance Architecture between the Centre
and States
2. Enhanced use of new data collection and sharing mechanisms for surveillance based on
unitized, citizen-centric comprehensive Electronic Health Records (EHR) with a unique
health identifier (UHID). As well, existing disease surveillance data and information
from periodic surveys will complement this information
3. Enhanced use of new data analytics, data science, artificial intelligence, and machine
learning, and
4. Advanced health informatics.
Going forward, India’s Public Health Surveillance will be based on individual EHR that
capture and amalgamate individuals’ health-care related information through the use
of a UHID. This is used in every clinical, laboratory or pharmacy visit and for vertical
disease control programs. Periodic surveys are positioned as additional complementary
methods to reassess the incidence and prevalence of diseases/risk factors, to adjust and
refine standard case definitions periodically, to define epidemic thresholds, and to refine
response levels and measures. A Surveillance Information Platform will store, analyse, and
auto-generate relevant reports for action. As well, this remains a repository for further
analysis and research, which will complement the available surveillance information.
Drawing on best practices from India and other developing and developed country
experiences, the document suggests next steps for India to move forward towards this
vision. All these steps are in alignment with the principle to raise the profile of surveillance
as a tool for the public good. The steps are suggested as a continuous cycle rather than
a sequential process. Vision 2035: Public Health Surveillance in India: A White Paper SCOPE OF THE DOCUMENT1
Vision 2035: Public Health Surveillance in India: A White Paper1 Vision 2035: Public Health Surveillance in India: A White Paper 2
SCOPE OF THE DOCUMENT
This is a vision document for Public Health Surveillance in India in 2035. The document
defines the vision, illustrates the architecture, describes the proposed flow of information,
lists key questions and considerations that are necessary to expand the scope of Public
Health Surveillance in India, defines the four building blocks and lists possible steps
towards achieving the vision.
The vision document briefly describes the progress made by India in Public Health
Disease Surveillance and builds on the existing experience of public health surveillance
systems with a focus on governance that is based on cooperative federalism, fostering
the involvement of state governments and using a bottoms-up approach. It aligns with
inclusive and sustainable growth and the principles stated in the National Health Policy 2017.
These include human resources that practice professionalism, integrity and ethics, and
public health services that reduce inequity and catastrophic costs for health care. The
focus is on Universal Health Coverage and patient-centred quality of care that is gender
sensitive, effective, safe, convenient and provided with dignity and confidentiality. The
multi-stakeholder approach with partnership and participation of all non-health ministries,
communities, academic institutions, not-for-profit agencies and the health care industry;
pluralism to optimise services wherever patients first seek care; decentralisation of
decision making; citizen centricity; and focus on expansion of Public Health Surveillance
to include non-communicable and occupational diseases, including mental health, are all
touched upon.
In addition to building on India’s past experience, the document draws on lessons
learned from global best practices including examples from Thailand, Taiwan, Germany,
the United Kingdom, the United States of America and Canada.
The document does not include funding and budget requirements. The analysis of
the capacity of existing institutions is only based on reviews of evaluation reports. The
document excludes a focus on COVID-19, even though India’s capacity and resilience
have been challenged by this pandemic. Instead, the document focuses on expanding
surveillance to be inclusive of non-communicable diseases, occupational, injury and
environmental conditions in a One-Health approach for Public Health Surveillance.
Next steps include the creation of a road-map or blueprint for action. As well, it would
be important to set up effective and responsive governance mechanisms that establish
political, technical, digital and managerial leadership in order to enable India reach this
vision by 2035. Vision 2035: Public Health Surveillance in India: A White Paper VISION 2035:
Public Health Surveillance
in India
2
Vision 2035: Public Health Surveillance in India: A White Paper3 Vision 2035: Public Health Surveillance in India: A White Paper VISION 2035: Public Health Surveillance in
India
Surveillance is defined as “a core public health function that ensures that the right
information is available at the right time and in the right place in order to inform public
health decisions and actions”
1
. In short, surveillance should be “Information for Action”
2,3
.
In 2035, India’s Public Health Surveillance will:
Vision
*Ability to predict a disease event or outbreak
π
Ability to respond positively with speed and sensitivity
#
Implies integration between centre, state and district, as well as between public and private health sectors
@
Refers to the 3 tier health care delivery system in India; primary care at Health and Wellness centres, sub-centres and primary health care centres,
secondary care at first level referral units and district hospitals (few specialities – medicine, obstetrics & gynaecology, paediatrics and emergency
care), and tertiary care at medical colleges and apex institutions (all specialists and super-specialists, equipped with high level laboratories for
advanced diagnostics and specialist procedures).
$
Prioritisation is a periodic exercise, repeated every 3-5 years, based on specific objective criteria, described later within this document.
^Includes clients/patients, governments, academia, industry, media and non-government organisations.
01
02
04
05
03
Be a predictive*, responsive
π
, integrated
#
and tiered
@
system of disease and
health surveillance that is inclusive of Prioritised
$
, emerging and re-emerging
communicable and non-communicable diseases and conditions. Readiness for
actions at community, facility and health and governance systems are key aspects
of the response.
Be a system that is primarily based on de-identified individual level patient
information which includes health care facility and laboratory data as key sources,
amongst others.
Serve public good through the provision of meaningful ‘Information for Action’
to relevant stakeholders^, with due attention to privacy and confidentiality of the
individual, and enabled with a client feedback mechanism.
Provide regional/global leadership in compliance with International Health
Regulations and management of events that constitute a Public Health Emergency
of International Concern
Be governed by an effective administrative and technical structure that is adequately
resourced.
1
Department of Health, PHE Transition Team. Towards a Public Health Surveillance Strategy for England.2012
2
Dworkin M S. Surveillance of Infectious Diseases Is Information for Action. AMA Journal of Medical Ethics. Virtual Mentor.2006;8(4):223-226.
DOI:10.1001/virtualmentor.2006.8.4.cprl1-0604.
3
World Health Organization. STEPS: A Framework for Surveillance. The WHO STEPwise Approach to Surveillance of Noncommunicable
Diseases (STEPS) Geneva, Switzerland.2003.
4 Vision 2035: Public Health Surveillance in India: A White Paper
BACKGROUND
AND INTRODUCTION
3
5 6Vision 2035: Public Health Surveillance in India: A White Paper
4
https://www.etymonline.com/word/surveillance and https://www.merriam-webster.com/dictionary/surveillance
5
Langmuir A D. The surveillance of communicable diseases of national importance. The New England Journal of Medicine.1963
DOI:10.1056/NEJM196301242680405
6
World Health Organization. Report of the Technical Discussions at the 21st World Health Assembly on National and Global Surveillance
of Communicable Disease. Geneva, Switzerland.1968
3.1 Definitions
The focus was towards ‘action’ that results from a system of surveillance. In this document,
we propose to use the definition ‘Surveillance is Information for Action’, drafted by an
expert group in 2012 by the Department of Health - Public Health Surveillance in the
vision document entitled, “Towards a Public Health Surveillance for England”.
3.2 Progress made thus far for Public Health Surveillance (PHS) in
India
The 1988 Cholera outbreak in Delhi and 1994 plague outbreak in Surat prompted the
Government of India (GoI) to constitute a National Apical Advisory Committee (NAAC)
in 1995. In 1997, the National Surveillance Program for Communicable Diseases was
launched. HIV Sentinel Surveillance (HSS) was perhaps one of the first nation-wide disease
surveillance programs which began in 1992 and was scaled up country-wide a decade
later.
The World Bank funded the GoI in 2004 for a ten year ‘Integrated Disease Surveillance
Project – IDSP’. This was later converted into a program and funded under the 12th plan
(2012-17) within the National Health Mission. The Central Surveillance Unit of the IDSP is
housed in the National Centre for Disease Control (NCDC), New Delhi.
The Indian Council of Medical Research (ICMR) has played a key role in strengthening
surveillance and research related to surveillance. The network of ICMR continues to
expand and at present has 106 Viral Research and Diagnostic Laboratories (VRDL), 35
diagnostic centres and a number of apex institutions. Together, these institutions have
played key roles in the identification of existing and new pathogens and their variants,
in controlling newly emerging infections (SARS, Nipah virus) and in estimating disease
burden using mathematical modelling for diseases like malaria and dengue fever.
The French defined surveillance in three words, ‘to watch over’
4
.
Langmuir defined surveillance as ‘the continued watchfulness over distribution
and trends of incidence through systematic collection, consolidation, and
evaluation of morbidity and mortality reports and other relevant data”
5
.
The Centre for Disease Control, Atlanta, US defined surveillance as ‘the
ongoing systematic collection, collation, analysis and interpretation of data
and dissemination of information to those who need it, in order that action
is taken.”
6
1963
20
years
later
1968 77Vision 2035: Public Health Surveillance in India: A White Paper
In 2019, the World Health Organization (WHO) in partnership with the GoI launched
the Integrated Health Information Platform (IHIP) within the IDSP program. The IHIP is
a digital web-based open platform that captures individualised data in almost real-time,
generates weekly and monthly reports of epidemic outbreaks and early warning signs
and captures response by ‘rapid response teams’, for 33+ disease conditions.
Other data sources capture information on diseases of national importance such as TB.
TB was made a notifiable disease in 2012 and the Nikshay platform serves as a source
of data to estimate burden and to track disease trends and outcomes. In late 2019, the
pandemic of COVID-19 has given further impetus to strengthen PHS in India.
Over the years, these various institutions, networks and programs have been fairly
effective. Small pox was eradicated in India in 1979, a year before its global eradication.
India was declared ‘Polio free’ in 2014, three years after the last case detection in India
in 2011. Epidemics of SARS, Nipah and rotavirus have been rapidly detected through
the efficient viral research and diagnostic laboratory network of ICMR, and have been
effectively controlled.
The ICMR network is playing a critical role in the containment of the COVID-19 pandemic.
The pandemic has catalysed the GoI’s laboratory infrastructure and health information
network for surveillance truly epitomising ‘Information for Action’. Vision 2035: Public Health Surveillance in India: A White Paper 3.3 Opportunities
There are important and timely opportunities within the Indian and global context that
can be leveraged to expand a Public Health Surveillance system in India.
There has been an explosion of digital technologies in health. NITI Aayog launched
the National Digital Health Blueprint in July 2019. Two key recommendations
from the National Digital Health Blueprint document are the use of a unique
health identity number (UHID) and the strengthening of electronic health records
in the public and private health care sectors. These two recommendations are
central to the basis for the future of surveillance in India, as outlined in this vision
document.
03
01
India recently rolled out the Ayushman Bharat scheme. One of the two inter-
related key features of this scheme is the expansion of primary health care
initiatives through the creation of 150000 Health and Wellness Centres (HWCs),
staffed by front-line workers and a new cadre of Community Health Officers.
The second is the Pradhan Mantri Jan Arogya Yojana (PMJAY). PMJAY is the
largest health assurance scheme in the world which aims to provide a health
cover of Rupees five lakhs per family per year for secondary and tertiary care
hospitalisation for poor and vulnerable families that form the bottom 40% of the
Indian population. The HWCs present an opportunity to conduct surveillance for
infectious disease, non-communicable disease, occupational health and injury
related conditions at the individual, family and primary care level. The PMJAY
could be a useful source of information to estimate out-of-pocket expenditure
on hospitalisation expenses, as well as for surveillance of diseases managed
within in-patient facilities.
02
The Integrated Health Information Platform (IHIP) under the IDSP is already
partially functional across several states. The experience in few states has
demonstrated its potential to detect epidemics, issue early warning signals,
capture outbreak investigation and respond appropriately. There is potential
for this platform to be rapidly scaled up across the country, to expand on the
number and type of disease conditions captured and to include data from the
private sector. However, surveillance cannot be seen as a separate activity from
patient care. This document emphasizes that surveillance can ride on top of a
unitized, citizen centric electronic health record (EHR).
Vision 2035: Public Health Surveillance in India: A White Paper8 9Vision 2035: Public Health Surveillance in India: A White Paper
The growth of smart phones and penetration of mobile telephones also presents
a huge opportunity for the paperless capture of almost real-time information,
inclusive of geo-coordinates. Additionally, the dissemination of meaningful
information to relevant stakeholders is feasible using smart-apps, a health portal
and to link to call centres that function as helplines and for other emerging
purposes.
04
Legal frameworks for health care and surveillance already exist within the
country. The Clinical Establishments Act (Registration and Regulation), 2010
has been passed and a number of states have been able to create directories
of clinical establishments and use this information to build upon and enhance
notification for disease, death and births, especially within the private sector.
Similarly, nationwide digitisation of the Health Management Information System
can enable timely and appropriate human resource recruitment and deployment,
especially of specialist services, including microbiologists and pathologists at the
block/district level.
Point-of-Care (PoC) diagnostics and screening tests, including gene testing for
infectious diseases and non-communicable diseases are rapidly developing. The
rapid development of PoC tests and hand-held devices will enable reaching
populations that are otherwise unreached by the health system and can facilitate
timely diagnoses and enable self-diagnosis as well.
Finally, institutions, including the ICMR and its apex institutions, the NCDC, and
the Centre and State governments, have demonstrated strong ability to rapidly
respond in order to contain, control and coordinate responses to ‘Public Health
Emergencies of International Concern’.
05
06
07
Vision 2035: Public Health Surveillance in India: A White Paper9 03
Anti-microbial Resistance – a growing threat: A third but important threat
that is emerging is the growing prevalence and complexity of Anti-microbial
Resistance (AMR). A decade after New Delhi lent its name, unwillingly, to
a dreaded super-bug gene, bla-NDM-1, the antibiotic resistant gene was
Vision 2035: Public Health Surveillance in India: A White Paper
3.4 Threats
01
02
Re-emerging and new Communicable Diseases: A number of new infections
have emerged and pathogens and diseases have re-emerged with resistant
or mutant strains. 75% of emerging/re-emerging diseases are zoonotic and
therefore a system of active animal surveillance and integration with agriculture
and other sectors is critical. Travel, trade and migration are growing and people’s
exposure to more exotic food, exotic animals and travelling to exotic locations
is increasing. There is increasing and more rapidly forming drug resistance
and there are syndemics of diseases which may either both be infectious as in
the case of HIV and TB, or in combinations where one is infectious while the
other is not, as in the case of TB and diabetes. Either way, these syndemics
adversely influence disease outcomes. Surveillance activities may consider these
interactions. Finally, the role of social, structural and biological determinants
of disease and death are rarely completely understood in terms of disease
distribution or prevalence.
Increasing rates of non-communicable diseases and acute and chronic
conditions: The Ministry of Health in its document “India – Health of Nation’s
States” (2019) states that 61% of mortality and 55% of the disability adjusted
life years were caused by NCD in 2016. NCD are not a single entity and
include cancers, cardiovascular conditions, respiratory diseases, diabetes,
and hypertension. Palliative care, mental health, emergency care related
to trauma, accidents, suicides and homicide are growing concerns as is
gender-based violence, abuse of children, accidents and occupational injury. The
elderly and adolescent are periods of life with increasing importance for public
health interventions, including surveillance, as both age groups tend to be very
vulnerable to disease, including accidents, abuse and injury. NCD surveillance
is often focused only on the surveillance of risk factors. The risk factors for
NCD are often multiple and are related to social behaviours including lifestyle,
food, exercise, stress and behavioural or addictive behaviours relating to drugs,
alcohol and tobacco, and environmental pollution. There is often a significant
time-lag between exposure and disease and this varies for different disease
conditions. Very often the ability to stage or capture this type of information
from hospital records or cancer registries is a challenge because of the lack of
standardisation and inadequate attention that is given to documentation.
10 11Vision 2035: Public Health Surveillance in India: A White Paper
7
Ranjalkar J, Chandy SJ. India’s National Action Plan for antimicrobial resistance - An overview of the context, status, and way ahead. J
Family Med Prim Care. 2019;8(6):1828-1834. DOI:10.4103/jfmpc.jfmpc_275_19
discovered in one of the pristine outposts on the planet—the Arctic. Between
2008, when the gene was first detected in a Swedish patient of Indian origin,
who had travelled to India that year, and 2019 when it was traced in Arctic, the
gene has been found in over 100 countries, and with new variants, confirming
the rapid spread of anti-microbial resistance, and showing what a big mistake
it would be to view this global challenge only through local lens. Factors
which contribute to AMR include overuse and misuse of antibiotics through
self-medication, indiscriminate access to antibiotics without prescription and
the use of pharmacies and informal healthcare providers as basic sources for
healthcare seeking, and the lack of knowledge about when to use antibiotics.
The addition of antibiotics to agricultural feed, also promotes drug resistance.
Veterinary use in livestock and poultry contributes to the problem of AMR.
Additionally, effluents discharged from pharmaceutical manufacturing units
also contribute to AMR development. In the face of growing ineffectiveness of
existing antibiotics, and absence of new discoveries of superior next generation
antibiotics, the world is heading to a public health emergency on AMR. It is
widely known that India bears a very high burden of AMR but in the absence of
detailed data, it is difficult to accurately estimate the size of the burden. AMR
has been recognized as one of the top priority focus areas of the WHO, which
has called for convergence between stakeholders and adoption of a “One-
Health” approach in tackling this challenge.
The Ministry of Health and Family Welfare launched the National Action Plan
on AMR (NAP-AMR) in April 2017, which highlights the need to tackle AMR
across multiple sectors such as human health, animal husbandry, industry and
environment in line with the “One-Health” approach
7
. However, at the state
level only a few states have released their State Action Plan for Containment of
Antimicrobial Resistance.
In India, the data on AMR that is being collated and archived appears to be too
little and too patchy to be fully representative to make meaningful assessment
and intervention. The ICMR collects AMR data from 25 public and private
hospitals and laboratories and while this is an important part, there is an urgent
need to expand on this for a country as vast and diverse as India. To better
understand and respond to antimicrobial resistance patterns and key drivers,
information about AMR incidence, prevalence, and trends may be gathered
as part of country’s disease surveillance mechanism. Stronger networks of
information sharing, and alignment with the global strategic research agenda
would help improve our understanding of the local, national and global AMR
patterns, burden and trends.
Vision 2035: Public Health Surveillance in India: A White Paper11 12Vision 2035: Public Health Surveillance in India: A White Paper
3.5 Challenges in India’s existing Public Health Surveillance
Despite significant progress and potential for an expanded and enhanced Public Health
Surveillance system in India, there are a number of challenges that need to be addressed
in the short term:
Implementation challenges – patchy surveillance, not comprehensive:
The IHIP is not yet fully operational across the country. There are a number of
notable implementation challenges. One of the important system design issues is
that data on the citizen utilisation of services for treatment of disease is separate
from notification mechanisms for disease outbreaks. There is a lack of uniformity
in outbreak investigation and reporting and there are limitations in geographic
coverage within states. HIV Sentinel Surveillance is a “program” activity, limited
in scope to two government facilities within a district. TB notification still misses
a modest proportion of estimated cases annually. There have been many pilot
projects implemented to enhance the existing surveillance system, including
influenza surveillance supported by the WHO, a CDC pilot to strengthen labs
and referral networks for Acute Encephalitis Syndrome (AES) and Acute Febrile
Illnesses (AFI). These remain as ‘research driven’ pilots, with limited resources and
willingness by governments to scale these up.
India needs to address these implementation challenges, cognisant of the fact
that relevant data on diagnosis and treatment provided to citizens across the
public and private sector may be captured for effective surveillance. Additionally,
a mechanism to transition, scale up and sustain pilot/innovative models for
surveillance is urgently needed.
Surveillance functions in vertical siloes of programs and institutions: Vertical
programs such as the National AIDS Control Program and the National TB
Elimination Program have achieved significant success in reducing disease
transmission, increasing the proportion of people who know their HIV or TB
status, enhancing the coverage of treatment among those infected or confirmed
with disease and reducing mortality from the disease. The Reproductive and Child
Health (RCH) program portal is able to track coverage of pregnant women for
antenatal care, institutional delivery and for maternal and child health outcomes.
However, surveillance data from these vertical programs are not yet fully integrated
within a single unified surveillance platform. Additionally, “Research” or the use
of existing data systems to answer important programmatic/policy questions has
been limited. Systematic quality control under surveillance was never optimally
addressed. There is limited ability of program implementation structures to work
in synchrony with research organizations and vice versa.
For example: Currently, similar data is collected by three organisations (IDSP,
ICMR’s Virology Diagnostic Research Laboratory Network and the National Vector
Borne Disease Control Program (NVBDCP) surveillance network), and there is
01
02 13Vision 2035: Public Health Surveillance in India: A White Paper
Private sector involvement in surveillance is limited:
The private sector is not a homogenous entity; it includes unregistered practitioners,
stand-alone clinics, pharmacies and laboratories, smaller nursing homes, medium
to large hospitals, medical colleges, corporate institutions and apex institutions.
Additionally, there are mission hospitals and independent trusts that run health
care facilities, which are not-for-profit institutions that are also included within the
private sector. Private sector participation in disease surveillance is minimal.
There are a number of questions that need to be explored before the private
sector is involved in Public Health Surveillance. For which disease conditions could
private sector be involved in surveillance? At what levels of care could private
sector be involved in Public Health Surveillance? How does one ensure consistency
and quality of a private sector site in surveillance, which is an on-going activity?
Under what circumstances and for which diseases could data from private sector
insurance be utilised for surveillance purposes?
A citizen centric EHR process where the citizen gets the advantage of his health
record from birth to death getting updated both from the public and private sector
will aid quality real time surveillance and ensure full population coverage. Care
provision becomes the main objective on which the surveillance could operate.
03
75% 62%outpatient inpatient
Inadequate linkage of morbidity with mortality data: The RCH program has
recently begun focusing on enhancing maternal and neonatal death review to
enable the identification of contributing factors and potential solutions to inform
health care service deliveries and prevent future deaths. However, maternal,
neonatal and child death surveillance and linking of mortality with morbidity reports
is not yet fully integrated. The data available with the vital registration system is
not yet shared/linked with IHIP, though this is possible through an Application
04
no mechanism for sharing or the unified use of the data. Even within the public
health system, there are a number of other institutions that are not yet involved
in surveillance. For example, the Central Government Health System, Railways,
Employee State Insurance (ESI) Corporation, and Defence related Army/Navy/Air-
force hospitals are not yet fully integrated into the Health Surveillance activities.
Vision 2035 envisages that surveillance will need to graduate from traditional data
entry systems based on vertical program implementation, to real-time data capture
from existing health records which are integrated using an UHID. Systems could be
enabled to transparently and safely exchange data based on standard protocols,
determined by the federated governance architecture. 14
Human resource challenges: The recruitment of human resources for State and
District Level Surveillance Units has been devolved to states, however, the response
of States to address these human resource gaps is varied. Health is a state subject,
while Health Surveillance is a national prerogative. Human resource vacancies and
staff capacity continue to plaque the system. The Joint Monitoring Mission 2015
8
reported 42% of vacancies at state and district levels and indicated that even at
the Central Surveillance Unit (CSU), positions tend to be filled by contract posts
or on deputation with individuals loaded with multiple other responsibilities. The
reasons for the lack of importance attributed to Public Health Surveillance by state
governments needs to be explored and addressed.
The relevant questions in this context are, “How do we ensure sufficient staff? Is
the supervisory and monitoring mechanism sufficient? How can we create and
sustain staff & structures?
Training of Public Health Core-Capacity: There are many examples of training
programs for public health professionals specifically in the area of surveillance.
For example, the United States Epidemic Intelligence Service through the Centre
for Disease Control (CDC) runs a two year Masters in Public Health course on
Epidemic Intelligence Service to develop a cadre of highly trained and skilled
epidemiologists for surveillance. The Public Health Agency of Canada runs a Field
Epidemiology Training Program to build public health capacity for responding to
urgent public health events. India lacks sufficient Public Health experts with this
expertise.
Relevant questions are: What additional skilling will existent or new HR require
in order to perform data analytics or use data science more efficiently? How can
these skills be expanded in scale and with speed? How much of resources could
Government at Central and State level invest in order to create and sustain this
expertise? How can partnerships with private medical colleges, public health
training institutes or Institutes of technology and management be leveraged for
this purpose? How can the Government objectively evaluate how skills of EIS
graduates are being utilised by the states, after course completion?
05
06
8
DGHS.Joint Monitoring Mission Report 2015
Programming Interface (API). Further, social and administrative barriers often lead
to under-reporting of deaths, even within the facilities. The linkage of mortality
and morbidity data even with infectious diseases is still limited.
How can we strengthen and integrate registration of vital events including birth,
marriage and death, in order to enhance surveillance?
Vision 2035: Public Health Surveillance in India: A White Paper 15Vision 2035: Public Health Surveillance in India: A White Paper
Limited use of digital, social and print media in surveillance: Social and print
media are increasingly being piloted for use in surveillance. A few states in the
country do have operational media scanning cells or media-advocacy initiatives
that help highlight disease outbreaks, or help identify a sudden increase in
hospitalisation or death due to an unusual event. These media sources can also
be used to promote disease prevention and containment actions at community
level during new infectious disease outbreaks (eg. During COVID-19, extensive
campaigns were used to promote social or physical distancing after hand-washing,
cough hygiene and wearing of masks), or to raise public awareness about danger
levels of indicators (eg. air pollution indices) and can help catalyse public health
responses.
How can we use social media for surveillance in India? Can we commission a
detailed impact evaluation to decide to what extent have social and print media
succeeded in making an original contribution to detecting early disease/outbreak
occurrences? How can India expand on its use of data science/“big data” strategies
for surveillance, that include social and print media (eg., Taiwan’s initial actions to
contain COVID-19 such as imposing a ban on flights from Wuhan, China and its
early travel restrictions were based on media reports of the outbreak in Wuhan,
much before WHO declared COVID-19 to be pandemic)
9
.
07
08
Limited focus on non-communicable disease surveillance: Non-communicable
disease (NCD) surveillance was introduced in many developed countries
almost 35-40 years ago. India faces the dual burden of non-communicable and
communicable diseases. The WHO predicted that by 2020, NCD would account
for 73% deaths and 60% of morbidity globally (WHO 2003). The IDSP has a division
of NCD that includes surveillance and other pilot programs which have focused
on diabetes, cardiovascular disease and cancers. The ICMR has played a crucial
role in enhancing surveillance of these three conditions through periodic surveys,
cancer registries and expansion of surveillance in newly formed regional centres
for cancer control. However, full integration of surveillance for NCD risk factors,
disease and death statistics, and surveillance of injury and accidents, air pollution
and its effects are yet to be included into surveillance.
How do we optimally use data collection from health records for NCDs? How
can we combine this information with periodic surveys on risk factors, disease
prevalence and death in order to provide a comprehensive picture and to enable a
continuum of care information, for the patient, the health care provider and policy
maker?
9
https://www.deccanchronicle.com/opinion/op-ed/130520/taiwan-has-just-65-active-440-total-covid-19-cases-despite-proximity.html 16Vision 2035: Public Health Surveillance in India: A White Paper
Fragmented and minimalistic approach in Occupational Health Surveillance:
Occupational Health Surveillance in India falls into two broad categories: Hazard
Surveillance and Health Surveillance. The NCDC has a division of Occupational
and Environmental Health. India has a National Institute of Occupation Health
(NIOH) in Ahmedabad, with regional institutes in Bangalore and Kolkata. With
ever growing urbanisation, increasing vehicular pollution and industrialisation,
Lead levels in air, water and soil are on the increase
10
. The NIOH has proposed
to conduct a prevalence survey of Lead toxicity, the commonest toxicity in urban
settings. Silicosis is the commonest occupational disease, seen commonly among
people working in mines and construction labour, most of whom belong to the
informal work sector
11
. The Employees State Insurance Corporation (ESIC) covers
most factory workers in the formal sector and a proportion of workers in informal
sector. Many formal sector workers also have other forms of health insurance that
cover hospitalisation expenses. However, despite this progress and availability of
occupational health data from these sources, Occupational Health Surveillance is
not a core component of India’s Public Health Surveillance. Silicosis is a notifiable
disease under The Factories Act, but it is not yet included under the Public Health
Act. Most doctors have minimal training on occupation health and disease.
Could India enhance and integrate Occupational Health Surveillance into its Public
Health Surveillance? What mechanism can we institute to ensure that national and
state governments facilitate consultations and collaboration between the Ministry
of Labour, Ministry of Mines and Ministry of Health in order to focus on priority
issues (eg., include Silicosis under the Public Health Act)? How can we ensure
routine monitoring of lead pollution in air, water and objects, and their toxicity, to
be included under surveillance? Could the most common, preventable conditions
under occupational settings be made notifiable and compensable (eg., noise-
induced deafness, muscular-skeletal disorders)? Finally, what other data sources
could we integrate in order to capture information on accidents and injuries (eg.,
medico-legal cases, road traffic accidents, etc.,)?
09
10
Patel K S, Ambade B, Sharma S, Sahu D, Jaiswal N K, Gupta S, Dewangan R K, Nava S, Lucarelli F, Blazhev B, Stefanova R, Hoinkis J.Lead
Environmental Pollution in Central India, New Trends in Technologies, Blandna Ramov, IntechOpen.January2010.DOI:10.5772/7590.
11
https://nhrc.nic.in/sites/default/files/NHRC_Interventions_on_Silicosis_27122016.pdf 17Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper
KEY CONSIDERATIONS
in Creating Vision 2035
4
17 18Vision 2035: Public Health Surveillance in India: A White Paper
KEY CONSIDERATIONS in Creating Vision
2035
Some of the key considerations in creating Vision 2035 for Public Health Surveillance
in India are listed here. Concerned stakeholders including policy makers and the
Government will need to address these questions in order to design and implement the
vision for Public Health Surveillance in 2035.
• Predicting/Forecasting and Preparedness for Epidemic Outbreaks for
communicable and emerging epidemics of non-communicable disease, both
re-emergence of known illnesses in different forms (influenza, MDR-TB), or new
disease outbreaks (NIPA virus, Corona virus, etc.,) or new geographic foci of
NCD.
• Guiding Prevention and Health Promotion Strategies: Identify new/hidden
reservoirs and sources of infection, block chains of rapid transmission and limit
the resulting morbidity, disability or death.
• Responding to Outbreaks and Guiding Future Programs of Disease
control: Institute standard protocols of a) characterising results beginning
with molecular tests, b) digitise results and ultimate action in real-time,
c) conduct genetic mapping to explore variations in the pathogen or the
susceptible host.
• Setting surveillance priorities: Could this include chronic and acute conditions,
especially in the context of occupational, environmental and nutritional health?
Could community, facility and system level components including health care
seeking and social determinants of health be included within Surveillance?
• Identifying and preparing the human resource capacity: How do we ensure
that we have a dedicated Public Health Cadre at block, district, state and
national levels, in adequate numbers and with composite competencies that
are regularly updated?
• Landscaping and strengthening laboratory capacity: How can we optimise
laboratory capacity within public and private sector? How do we strengthen
Point-of-Care diagnostics, self-testing protocols and referral networks to
reduce time taken to produce screening or diagnostic results that are reliable,
valid and useful to the patient and provider? How do we ensure that laboratory
results are smoothly amalgamated with relevant clinical and socio-demographic
information that contributes not only to better patient care but also to public
health actions?
What could be the goals of Public Health Surveillance?
What could immediate next steps include? Could it include: 19Vision 2035: Public Health Surveillance in India: A White Paper
• Digital Health interventions
• Integrated Communication Technology
• Science, Technology, Social and Business platforms
How can Public Health Surveillance leverage existing talent and
platforms?
• Unique Health Identifier
• Unified Health/Medical record
• Standard data sharing protocols
• Interoperability between systems and programs
How can we use routinely collect individual level patient data to
create population based datasets?
• Plant, animal and human disease statistics
• Environmental indicators
• Economic data
• Governance and Cooperative Federalism
• Data holding: Meta-data, data standards, case definitions, data protection, etc.,
• Patient care pathways and continuum of care: Individual, Family, course of
disease, etc.,
• Open mechanisms for inputs/outputs: Call centre, India Health Portal, Health
Apps, Insurance
Could Public Health Surveillance integrate different sources
of data for analyses, and how do we ensure an inter-sectoral
response?
What is the design of a Federal National Health Implementation
Architecture?
• Developing and mobilizing technologies and methodologies: Could there be
a horizon scanning for early warning signs through platforms such as WHO,
PROMED and others? What is the role of social media? How do countries
learn quickly on how to prevent, respond and act based on experiences of
new outbreaks in a different part of the globe? How do we ensure ‘Big data’
12
management and integrate Artificial Intelligence and machine learning into
Surveillance platforms?
• Coordination and governance: Policy, Technical, Managerial and Digital?
12
Healthcare big data refers to collecting, analysing and leveraging consumer, patient, physical, and clinical data that is too vast or
complex to be understood by traditional means of data processing. Big data is often processed by machine learning algorithms and
data scientists. https://partners.healthgrades.com/faq/what-is-healthcare-big-data 20Vision 2035: Public Health Surveillance in India: A White Paper
• Table 1 (Pg. 38) is a list of diseases targeted for elimination by the WHO. How
can India use this list to define their own list of diseases and time-lines for
Disease Elimination?
• Disease eradication appears to be a much more challenging goal and until date
has been achieved only with smallpox. However, with many diseases slated for
elimination by 2030, could the agenda for surveillance post-disease elimination
also be defined? For example, many developed countries are today facing re-
emerging epidemics of syphilis and other sexually transmitted diseases, which
were eliminated previously.
Which Diseases could India target for Elimination by 2030? What
could be the pathway to elimination?
• Community/public access
• Access to intellectual property
• Apex institutes to stimulate research on diagnostics and vaccines
• Publication of big data science and data analytics
• Business development for mass electronic manufacturers
How does Public Health Surveillance broaden data access for
relevant stakeholders to include all concerned while ensuring
required patient confidentiality? 21Vision 2035: Public Health Surveillance in India: A White Paper
5
THE BUILDING BLOCKS
FOR VISION 2035:
Public Health Surveillance
in India
21 22Vision 2035: Public Health Surveillance in India: A White Paper
THE BUILDING BLOCKS FOR VISION
2035: Public Health Surveillance in India
5.1 Governance: Principle - Develop an eco-system for surveillance
A federated governance system that is based on ensuring ‘public good’ and that pools
public health surveillance resources and information both for the ‘Centre’ and ‘States/
Union Territories’, is the foundation for Surveillance. A proposed architecture of future
surveillance is depicted in Figure 1. Governance includes three functions.
A political function that includes resource allocation and guidelines for
its use, enacting legislations relevant to control of epidemic diseases and
creating new policies.
A technical function that includes priority setting, protocols for disease
outbreak containment and management, case-definitions and setting
thresholds for labelling the type of disease outbreak/epidemic.
A managerial function that includes planning, implementation, monitoring
and evaluation. Each group is constituted as per existing guidelines.
Figure 1: The Architecture of Public Health Surveillance in 2035
FLW: Front-Line Worker, HWC: Health and Wellness Centre, DH: District Hospital, CHC: Community Health Centre,
MC: Medical Colleges, PHC: Primary Health Centre, ESIC: Employees State Insurance Corporation.
P
O
L
IT
IC
A
L T
E
C
H
N
I
C
A
L
NationalStateInformation for ActionInformation for Action
Program
Governance
Surveillance Information Platform
Unified e-Health Record
ELECTRONIC HEALTH RECORD &
ELECTRONIC MEDICAL RECORD
UHID
Hospital Management Information System
(e-Hospital)
Health Facilities
Public
· HWC
· CHC
· PHC
· MC
· DH · Hospitals
· Clinics
· Defence
· ESIC
· Railways Enumeration
UHID
FLW
Citizens
Health Portal
My Health App
Health Digi Locker
· Strengthened Research
· Apex Laboratories System
· Special Studies
· National Surveys
· Plant & Animal Disease Statistics
· Environmental Health Indicators
National Programs:
NACP/NTEP/IDSP
Occupational Health &
Injury Surveillance
Private Insurance & Govt.
Assurance Schemes data
Private Central Government 23Vision 2035: Public Health Surveillance in India: A White Paper
Surveillance itself functions on a single Surveillance Information Platform that amalgamates
all relevant information from multiple sources. Initially, this information can come from
existing vertical and integrated disease surveillance programs. However, over time,
this would be primarily driven from electronic health records (EHR) of populations and
medical records of patients, that are individualised and identified through the use of a
unique health identifier (UHID). Information from vertical and integrated disease control
programs, hospitals and health centres, laboratories and pharmacies, insurance related
routine medical check-up, PMJAY and other insurance records, and occupational health
surveillance will all be amalgamated into the EHR. In alignment with the Principle of
‘One-Health’ environmental health surveillance, plant and animal disease surveillance will
also be integrated into this Surveillance Information Platform. National surveys, special
studies and research will be used periodically to validate case definitions and to address
gaps within the EHR based surveillance.
Once the Surveillance Information Platform is fully functional, future Governance will
include the following:
The Priorities for surveillance and indicators of success are clearly defined and performance
is linked to Health Resource Allocation. Tools, thresholds and timelines for early warning
signs and outbreak reports are established, re-examined and redefined, periodically.
The performance of the Public Health Surveillance ecosystem is reviewed periodically
by an expert group represented by political, bureaucratic and scientific leadership. Key
stakeholders are periodically reviewed for their performance, measured by their use of
‘Information for Action’. The expertise and network intelligence that exists within apex
and research institutions is harnessed and specialist human resources are recruited,
developed and retained in adequate and appropriate strength. Continuous quality
improvement and legal mechanisms are in place to ensure global/regional leadership
of India’s public health surveillance. Finally, novel partnerships are established with
developed and developing countries for continued learning and development, detecting
emergence of new pathogens, identifying new phenotypes and genotypes of known
pathogens, for monitoring anti-microbial resistance, new diagnostics, nanotechnology
and its applications, etc.,
5.2 Information Systems linked with robust lab networks as data
sources for Surveillance
New data sharing mechanisms ensure that Surveillance does not replace existing vertical
and integrated programs, but amalgamates the data on a ‘Surveillance Information
Platform’ in near real-time using data-sharing mechanisms, rather than traditional data-
entry systems. In order to enable this, the use of a Unique Health Information Identifier
(UHID) number, as envisioned in the National Digital Health Blueprint (2019), becomes
universal. This facilitates linkage between clinical, laboratory and pharmacy related data,
allows individual level data capture on disease diagnosis, management and outcomes,
as well as analysis of disease patterns, prevalence and trends at the population level.
Additionally, the UHID reduces duplication and enables analysis of new trends by
individual socio-demographic characteristics and emerging risk factors, and appropriate 24Vision 2035: Public Health Surveillance in India: A White Paper
allocation of resources with measurement of disease burden. All information is captured
from an EHR or a standard format, that is again universalized and standardized for use
within the public and private health system, as well as other points of contact with
service delivery, such as those provided outside the traditional health system, including
rehabilitation services, social and welfare services, etc., Additionally, data collection
leverages new technologies including the use of hand-held devices, rapid throughput
screening devices in ports and entry points, mobile platforms and digital technologies,
call-centre approaches, new ‘Point-of-Care’ screening and diagnostic tests that can be
used for an array of diseases, self-collected and tested swabs, saliva and urine tests that
can be done at home or in community settings, but with automated data capture. Data
outputs from laboratories, pharmacies, health institutions and the insurance sectors, are
captured directly in near real-time, compiled using standard protocols, and available for
access, as and when needed. Data sharing agreements are configured and contracted,
with due consideration to privacy and confidentiality of the individual.
5.3 Data Analytics (including Predictive Analytics)
Definitions of disease are standardized for surveillance that are agreed upon by clinician,
researcher and epidemiologist, and between veterinary, plant and human sciences, in
alignment with the ‘One-Health’ principle are universally utilised. Interoperability or free
exchange of information from different systems and between different disease control
program platforms are established to ensure that data is linkable and de-identified, stored
safely and is available for refined and advanced analysis. New risk factors that emerge
from research are rapidly integrated into models for disease prediction, especially for
non-communicable disease (NCD) conditions. New Data Science analytical tools and
methodologies including molecular epidemiology, genomics, mathematical modelling,
prediction techniques and artificial intelligence are integrated for use within Surveillance
Systems to inform public health responses and policy.
These may include:
Automated systems that flag/alert
authorities of potential threats based
on predefined thresholds for identified
diseases
Analysis by researchers, modellers
and others, which can help inform and
improve case definitions
Predictive systems which flags authorities
based on patterns of symptoms
Tools for performance management
measurements 25Vision 2035: Public Health Surveillance in India: A White Paper
5.4 Information for Action: Principle - ‘For Public good’
Public Health Surveillance undergoes a paradigm shift from being visualized as a core
Government function, to one that is ultimately aimed at making relevant information
available to the common citizen for public good. New dissemination techniques include
the use of health informatics, electronic and digital platforms, social media and individually-
accessed digital apps, with password-protected information. Health information ethics,
patient privacy and confidentiality will be an integral part of any process which uses these
tools for Public Health Surveillance.
New stakeholders are included. In addition to the patient, parent/guardian and the
practitioner, the private or public institutions (that are academic, service-oriented,
research-focused, product development-oriented or policy-centred), the policy maker,
the press and the politician will be included. However, only meaningful, select and
relevant information will be made available to stakeholders on an as needed basis, in
order to ensure patient confidentiality.
Surveillance is ‘Information for Action’. Examples of action at different levels is illustrated
below. This is not an exhaustive list.
Citizen Level: Preventive actions to limit disease transmission and optimize
health outcomes (actions for self-protection, self-quarantine, self-testing, self-
care, timely access to the right services, adherence to treatment, etc.)
Block/District level: Outbreak investigation, Active and passive case-finding,
Contact tracing, Isolation of index, Quarantine of presumptive patients, Social/
physical distancing, Limiting air, water, soil, food, blood and its products and
vector borne transmission, Treatment of confirmed cases/contacts, Chemo/
Immuno-prophylaxis for susceptible individuals, etc.,
State/National level: Legislation, Resource Allocation, Monitoring trends,
Disseminate meaningful information to relevant stakeholders, Monitor actions
at different levels, etc.,
International level: Reporting under International Health Regulations and for
Public Health Emergencies of International Concern.
For NCD and Occupational Health: Minimise exposure to known risk factors,
regulate sources of environmental pollution, dedicate resources, inter-sector
collaboration. 26Vision 2035: Public Health Surveillance in India: A White Paper
Response Team
Administration &
Policy Makers
Automated
Alert System
Plant & Animal
IndicatorsFront Line Workers
Citizens
Health Care
Provider
Laboratory
Electronic
Health Record
Electronic
Lab Record
Electronic Personal
Assesment Record
Surveillance
Information Platform
Data Warehouse
Pharma Sales
Data
Electronic
Medical Database
Environmental
Indicators
National
Research
& Surveys
Media Scans
Gov. Data
Scientists
and Researchers
National
Programs
Citizens
Open Data
POLITICAL
Governance
TECHNICAL
NATIONAL
MANAGERIAL
STATE
Information
for Action
UHID
Enumeration
Data AnalyticsService Provision Electronic Data Interchange & Collation
Diagnostics
Seek\Receive Care
Enroll Citizen
Figure 2: The Proposed Flow of Information for Public Health Surveillance in 2035
The proposed flow of information is depicted in Figure 2. 27Vision 2035: Public Health Surveillance in India: A White Paper
6
STEPS TOWARDS
ACHIEVING VISION 2035:
Public Health Surveillance
in India
27 28Vision 2035: Public Health Surveillance in India: A White Paper
STEPS TOWARDS ACHIEVING VISION
2035: Public Health Surveillance in India
Drawing from India’s past experience and global best practice, this document recommends
steps to building Public Health Surveillance in India. The steps are not in order of priority.
However, they have been presented as clusters and in a cycle of events, as depicted in
Figure 3.
6.1 Raise the profile of Public Health Surveillance
Public Health Surveillance in India is often considered as a separate activity, not related
directly to health care service delivery. It is sometimes viewed as a stand-alone activity,
with different institutions responsible for different aspects, as depicted in Figure 5
(Pg. 43). It is important to raise the profile of Public Health Surveillance in India and to
position Public Health Surveillance as a tool for public good. In order to enable this,
Information for Action may be made available to multiple stakeholders, including the
citizen and the political and bureaucratic leadership at the central, state and district level.
It is of paramount importance for an effective and responsive governance structure to
be set up immediately. Periodic coming together of this leadership will be important to
charter a way forward, as well as to deal with Public Health Emergencies of International
Concern, as and when they arise. The governance team will guide the development of
the blueprint or action plan that needs to be developed. The suggested architecture for
PHS in 2035 is depicted in Figure 1 (Pg. 22) and Figure 2 (Pg. 26).
Figure 3: The Way Forward: Public Health Surveillance in India
Meaningful
Information
Relevant
Stakeholders
Responsive,
Timely &
Appropriate
Actions
Citizen Centric
Political & Technical
Leadership
Digital Technological
Leadership
Managerial
Leadership
Policy
Leadership
Improve Core
Functions
Improve Support
Functions
Improve System
Attributes
Raise the Profile
of Public Health
Surveillance in India
Define scope.
Identify broad
categories
Prioritise Diseases/
Conditions for
Surveillance Use STEPwise
approach to integrate
NCD Surveillance
Encourage
Innovations
Strengthen Lab
Capacity and
Referral Networks
Align with Ayushman Bharat:
Enhance Community based
surveillance
Streamline data
collection techniques
Strengthen data
analysis techniques
Systematically
disseminate
Information for
Action 29Vision 2035: Public Health Surveillance in India: A White Paper
13
The Internet of Things (IoT) refers to a system of interrelated, internet-connected objects that are able to collect and transfer data
over a wireless network without human intervention. https://internetofthingsagenda.techtarget.com/definition/Internet-of-Things
IoT. An IoT system consists of sensors/devices which “talk” to the cloud through some kind of connectivity. Once the data gets to the
cloud, software processes it and then might decide to perform an action, such as sending an alert or automatically adjusting the
sensors/devices without the need for the user. https://www.leverege.com/blogpost/iot-explained-how-does-an-iot-system-actually
work
6.2 Create/Strengthen an Independent Health Informatics Institute
Public health informatics has an essential role in data collection, collation, analysis and
transmission for public health surveillance and related actions. A dedicated Independent
Health Informatics Institute will need to be created to support and guide innovations and
analytic activities, including the use of Internet of Things (IoT)
13
surveillance activities. It
is essential for both the centre and states to recognise the importance of Public Health
Information for Action and allocate resources and dedicate appropriate technology to
manage Health Information for Action.
6.4 Use a WHO STEPwise approach to include NCD Surveillance
Surveillance for NCD has been fragmented. The WHO suggested the STEPwise approach,
that is inclusive of death, disease and risk factors. Tables 3a and 3b ( Pg. 43) in the annexure
depict this approach. The STEPwise approach can be implemented beginning with Health
and Wellness Centres in India, wherein front-line workers and Community Health Officers
6.3 Define the scope of surveillance into broad categories of diseases/
conditions, keep it simple and strategic
India has traditionally focused on Surveillance for Communicable/Infectious Diseases.
Though initiatives are in place for NCD, Occupational Health, Injury and Environmental
Health Surveillance, these are not yet given adequate surveillance attention. In order
to facilitate strengthening of these areas, it may be important to create/identify nodal
structures for different diseases and conditions. As an example, the Department of Disease
Control, Ministry of Health, Thailand classified and focused on five main categories of
disease that were prioritised for Health Surveillance: a. Acute Communicable Disease,
b. HIV and TB, c. Non-communicable disease, d. Injury, e. Occupational and environmental
disease. India may decide to follow these same principles. Currently, surveillance is
in place for the first three disease groups/conditions. The list of diseases under the
Integrated Disease Surveillance Program is shown in Table 2. Additionally, HIV and
TB function as vertical programs, with their own surveillance systems. Inter-ministerial
cooperation between ‘labour’ and ‘health’ is essential to expand on Occupational
Disease Surveillance and to capture ‘injuries’. India can redefine the scope and priorities
for disease surveillance and establish /strengthen structures that can be held accountable
for each of the prioritised disease categories. The exercise can be repeated, at least once
every three to five years. In addition to disease based surveillance, response protocols
and mechanisms for event based surveillance especially for Public Health Emergencies of
International Concern, may be strengthened. 30Vision 2035: Public Health Surveillance in India: A White Paper
6.5 Prioritise Diseases/Conditions that will be the focus for
Surveillance/Disease Elimination
India can use multiple criteria, based on available information to prioritise diseases and
conditions under each of the five broad categories that were listed above in the Thailand
example. As an example, Germany used ten criteria including a. incidence, b. work
and school absenteeism, c. health care utilisation, d. chronicity of illness and sequelae,
e. case fatality rate, f. proportion of events requiring public health action, g. trend, h. public
attention including political, media and public perception, i. prevention possibilities and
j. treatment possibilities for prioritising diseases for surveillance, as depicted in Table 4
(Pg. 41). India could use similar criteria or adapt the same, based on local context. WHO
has listed diseases for Elimination by 2025 and 2030, as depicted in Table 1 (Pg. 38). India
could create its own list of diseases slated for elimination by 2030. India could adapt/design
the prioritization criteria based on the context of each state or district, given its diversity.
6.6 Improve Core Support Functions, Core Functions and System
Attributes
Revati K Phalkey et al in 2015 published, “Challenges with the implementation of an Integrated
Disease Surveillance and Response (IDSR) system: systematic review of the lessons learned”
highlighting the importance to first improve core support functions including health system
support, workforce support and technological support, as depicted in Figure 6 (Pg. 44).
Once this is taken care of, enhance core functions of surveillance including case definition,
case confirmation, case registration, case notification, data management, data analysis,
outbreak preparedness, outbreak detection and response and feedback. All the while, it
would be important to focus on improving system attributes including Simplicity, Flexibility,
Timeliness, Completeness, Consistency, Representativeness, Acceptability, Data Accuracy,
Sensitivity, Positive Predictive Value and Stability.
6.7 Streamline data sharing, analysis, dissemination and use for action
The first and foremost pre-requisite for a unified Surveillance system is the need of
a unique health identifier (UHID) for every individual. This will not only help to link
Syndromic, Presumptive and Laboratory records that are currently used, but can also
be potentially used to link morbidity and mortality data. It also allows for better NCD
surveillance - for incidence/prevalence and understanding health outcomes - as well
as for informing allocation of resources. India has made great progress by achieving
almost universal coverage of the UID (Aadhar). There is potential to use UID or a similar
system to ensure that every individual has a UHID, which will enable the patient and
health care provider to have complete information on the health and disease status
of the individual. The access to this information can be controlled by incorporating
watch over the health and wellness of a fixed population, with digitised person-centred,
family based records. Personal health records, hospital and insurance records and surveys
can complement this information. 31Vision 2035: Public Health Surveillance in India: A White Paper
6.8 Encourage Innovations
India is well known for its innovative approaches in Health and other sectors. Innovation
could be encouraged within Public Health Surveillance as well. As an example, Public
Health Surveillance England mentioned steps where innovation can be explored within the
public health surveillance loop to include new collection techniques, new case definitions
or new risk factors/groups, new Point-of-Care diagnostics and screening tools/devices,
new analytical tools, new dissemination techniques, new stakeholders, new evidence/
research findings, as depicted in Figure 8 (Pg. 46). It would be necessary to identify
opportunities for implementation of these innovations within districts/states to learn from
and then ensure successful scale up and integration into the Public Health system.
Barker I, Brownlie J, et al in their foresight document entitled, “Infectious Diseases:
preparing for the future. A vision of future detection, identification and monitoring
systems”, developed a framework for future detection, identification and monitoring
systems, which is depicted in Figure 9 (Pg. 47). The framework explored consideration
of the analysis of future threats, the analysis of societal contexts and the reviews of
future science to be contributors of an evaluation of future Detection, Identification and
Monitoring (DIM) systems. The future DIM systems would predict and suggest public
health actions necessary for disease control.
6.9 Align with Ayushman Bharat
The Health and Wellness Centres present a unique opportunity to strengthen community
based surveillance at the primary health care level, by capacitating front-line health
personnel to perform syndromic reporting for infectious disease and screening for risk
factors or for disease markers for common NCD and communicable diseases, using basic
verbal screening tools or Point-of-Care diagnostics and devices. Additionally, information
captured under the PMJAY assurance scheme and private and public insurance sector
insurance schemes can also be amalgamated for disease surveillance of hospitalisation
episodes.
one-time passwords (OTP). One will need to be cognisant of the rulings of the judiciary
on the pertinent use of the UID for health and social protection. The UHID and EHR
become core building blocks in order to streamline data sharing. Figure 7a and 7b
(Pg. 45). depict core building blocks used in different contexts. Actions dependent on
the use of social, electronic, print and digital media can be explored to build on data
analytics, dissemination and for making meaningful information available for relevant
stakeholders. Actions in response to epidemic disease outbreaks, high or clustering of
NCD prevalence and occupational diseases have been mentioned previously. 32Vision 2035: Public Health Surveillance in India: A White Paper
6.10 Strengthen laboratory infrastructure, referral networks and
community based surveillance
A well-functioning and robust laboratory system at various levels of healthcare is critical
to establishing an efficient disease surveillance program. States may have decentralised
diagnostic facilities in order to conduct surveillance of epidemic prone diseases. The IDSP
has developed district public health laboratories that are being strengthened under the
National Health Mission. These efforts may be accelerated and scaled up. The need for
the rapid, accurate, affordable and robust diagnostics is obvious. The WHO released the
first edition of essential diagnostics list (EDL) in May 2018. The ICMR finalised the country’s
first National Essential Diagnostics List (NEDL), a year later. NEDL has considered all
levels of health care – village level, primary, secondary and tertiary care and builds upon
the Free Diagnostics Service Initiative and other diagnostics initiatives of the Ministry
of Health to provide an expanded basket of tests at different levels of the public health
system. Availability of quality assured diagnostics at various levels of healthcare is critical
for disease prevention, control and surveillance.
Primary Health Centres would need strengthened capacity of front-line workers for
community-based screening for presumptive and active cases, active case-finding,
contact tracing, to promote barriers to disease transmission including social/physical
distancing, hand-washing, cough hygiene, use of toilets and safe drinking water, etc., as
relevant. Laboratories at the primary care level can be strengthened with Point-of-Care,
community-based or self-testing kits, in order to screen for or confirm disease, that may
be endemic or new, within local geographic settings.
Block level labs may be strengthened in order to increase the efficiency of public health
interventions and to decrease the load on district and state level labs. Accurate diagnoses
of common endemic diseases in the region, based on common syndromes (eg., Acute
Febrile Illness) is feasible in block/district level labs. Block level labs can confirm diagnosis
early, during disease outbreaks and after the outbreak and thus support the right decisions
related to action and intervention in a timely manner.
Additionally, it would be important to strengthen referral networks to ensure that
primary care benefits from clinical and laboratory disease/risk factor confirmation that
is made widely available at block and district level. This can be effectively implemented
by putting into place PoC screening and diagnostics; making available and accessible
community-based/ home-based testing kits, activating blood/ urine/ saliva/ sputum/ hair
based sample collection, transportation, testing and reporting mechanisms, and rapid
throughput screening or hand-held devices, in addition to enabling front-line and mid-line
health personnel with smart phone apps and mobile based and digital technologies.
It would be important to strengthen nodal institutions with human resource, infrastructure,
equipment and supplies for genotype, phenotype, detection of pathogenic mutants and
for antimicrobial resistance. Additionally, these can be made responsible and accountable 33Vision 2035: Public Health Surveillance in India: A White Paper
14
Jian S W, Chen C M, Lee C Y, Liu D P. Real-Time Surveillance of Infectious Diseases: Taiwan’s Experience. Health Secur. 2017 Mar/
Apr;15(2):144-153.DOI: 10.1089/hs.2016.0107.PMID: 28418738; PMCID: PMC5404256.
An illustrative example Surveillance for Infectious disease alone is the Public Health
Surveillance of Taiwan
14
, illustrated in Figure 10 (Pg. 48).
Figure 4: Integration of PHS into Ayushman Bharat: 3-tiered Approach
Integrated Health Information Platform
Pheno/genotypes,
molecular-based tests,
pathogen mutants,
resistance patterns
Laboratory confirmation,
Clinical case definition
Syndromic/Presumptive
Reporting for ID
Screening data for NCD
Strengthen
Lab capacity
Epidemic Threshold
Trend Analysis
New Variant/concern
Adherence to
Standards
Strengthen
referral networks
Strengthen
community level
surveillance
Apex
Institutes
District Hospitals
Primary Health
Centres
Health & Wellness
Centres
PMJAY
Information
for quality assurance of molecular, serological and microbiological testing in partnership
with intermediate and state level reference laboratories. Private institutions can be
engaged through a collaborative and mutually beneficial framework. Finally, it would be
important to task and fund institutions to ensure Continuous Quality Improvement. The
integrations into Ayushman Bharat and the three-tiered approach to lab strengthening
are depicted in the Figure 4. 34Vision 2035: Public Health Surveillance in India: A White Paper 35Vision 2035: Public Health Surveillance in India: A White Paper Vision 2035: Public Health Surveillance in India: A White Paper
CONCLUSION7
35 36Vision 2035: Public Health Surveillance in India: A White Paper
CONCLUSION
In conclusion, India’s Vision 2035 for Public Health Surveillance envisions integration within
the three-tiered health system, strengthened community based surveillance, expanded
referral networks and enhanced laboratory capacity. The EHR becomes the main basis
of surveillance and is complemented by periodic national/state/district level surveys,
special studies and research in order to reconcile the threshold and redefine standard
definitions of cases, as disease patterns evolve. Surveillance is not solely dependent on
individual disease driven active or passive surveillance systems, though these may remain
important contributors to surveillance information. The building blocks for this vision are
an interdependent federated system of Governance between Centre and States, new
data sharing that is not dependent on traditional systems of data entry, but one that
is positioned over and above existing disease surveillance programs. Surveillance uses
new analytics, health informatics and data science and innovative ways of disseminating
‘Information for Action’. This will further thrust India to be a global/regional leader in
Public Health Surveillance. 37Vision 2035: Public Health Surveillance in India: A White Paper
ANNEXURES
Vision 2035: Public Health Surveillance in India: A White Paper37 38Vision 2035: Public Health Surveillance in India: A White Paper
TABLE 1 WHO list of Diseases slated for Elimination and their Timelines
Intervention Disease
Eradication:
Worldwide
reduction to zero
Interruption of
local transmission
Elimination as
a public health
problem
Small pox
Polio
Yaws
Dracunculiasis
Malaria
Measles
Rubella
Leprosy
Chagas
Sleeping sickness
Onchocerciasis
Schistosomiasis
Visceral Leishmaniasis
Cholera
Lymphatic Filariasis
Trachoma
Mother-to-Child
Transmission: HIV and
Syphilis (and HepB)
Maternal and neonatal
tetanus
Rabies
Soil transmitted
helminths
Global
Global
Regional: Americas
Regional: Africa
Global
Regional
Regional: Indian
sub-continent
20/47 endemic
countries
Global
Global
Global
Global
Global
Global
10 years from 1966
2014
To be decided
To be decided
2030
2020
2020
2020
2015
2022 Latin America
and 2025 Africa
2025
2020
2030
2020
2020
2030
2020
2030
2030
RegionTarget Dates Vision 2035: Public Health Surveillance in India: A White Paper 39
TABLE 2 Diseases under Integrated Disease Surveillance Program
L form
1. Dengue / DHF / DSS
2. Chikungunya
3. JE
4. Meningococcal Meningitis
5. Typhoid Fever
6. Diphtheria
7. Cholera
8. Shigella Dysentery
9. Viral Hepatitis A
10. Viral Hepatitis E
11. Leptospirosis
12. Malaria: PV, PF
1. Acute Diarrhoeal Disease (Cholera)
2. Bacillary Dysentery
3. Viral Hepatitis (A/E)
4. Enteric Fever
5. Malaria (PV, PF)
6. Dengue / DHF / DSS
7. Chikungunya
8. Acute Encephalitis Syndrome (JE)
9. Meningitis
10. Measles
11. Diphtheria
12. Pertussis
13. Chicken Pox
14. Fever of Unknown Origin (PUO)
15. Acute Respiratory Infection (ARI) / Influenza Like Illness (ILI)
16. Pneumonia
17. Leptospirosis
18. Acute Flaccid Paralysis < 15 Years of Age
19. Dog bite
20. Snake bite
21. Any other State Specific Disease (Specify)
22. Unusual Syndromes NOT Captured above (Specify clinical
diagnosis); eg., scrub typhus
Diseases under Presumptive (P form) Surveillance 40Vision 2035: Public Health Surveillance in India: A White Paper
NCD
Measures
Risk factors
(the future)
Diseases
(the present)
Deaths
(the past)
Core
Expanded
Core
Optional
(examples)
Questionnaire-
based report on key
behavioural risk factors
Hospital or clinic
admissions, by age
and sex
Death rates by age
and sex
Socio-economic and
demographic variables,
years of education, tobacco
and alcohol use, physical
inactivity, intake of fruit and
vegetables
Ethnicity, Income,
Education, Household
indicators, Dietary patterns
Other health-related
behaviours, mental health,
disability, injury
Questionnaires plus
objective physical
measurements
Rates and principal
condition by age. sex
and principal conditions:
communicable diseases,
NCDs and injury
Death rates by age,
sex and broad cause of
death (verbal autopsy)
Measured weight
and height, waist,
circumference,
blood pressure
Hip circumference,
pulse rate
Timed walk,
pedometer, skinfold,
thickness
Questionnaires plus
objective physical
measurements plus bio-
chemical measurements
Age, sex and cause-
specific disease
incidence or prevalence
Death rates by age, sex
and cause of death
(death certificate)
Fasting blood
sugar, total
cholesterol
HDL-cholesterol,
triglycerides
Oral glucose
tolerance test,
urine examination
Step 1
Step 1 (Self Report)
Step 2
Step 2 (Physical)
Step 3
Step 3 (Biochemical)
TABLE 3a
TABLE 3b
The WHO STEPwise approach to NCD surveillance
STEPS approach to risk factor assessment 41Vision 2035: Public Health Surveillance in India: A White Paper
No.
1
2
3
4
5
6
7
<1/100 000
This pathogen
causes a negligible
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a negligible
proportion of health
care utilisation due
to an infectious
illness
This pathogen
causes a negligible
amount of chronicity
or persistent
sequelae (estimate
prevalence of those
being <0.1/100 000
population)
<0.01%
A small proportion of
the estimated total
number of events or
exceptional events
require public health
actions (<25%)
Diminishing incidence
rates
Incidence
(including illness
and symptomatic
infection)
Work and school
absenteeism*
Health care
utilisation (primary)
Chronicity
of illness or
sequelae*
Case fatality rate**
Proportion of
events requiring
public health
actions (see
Note 2 for
explanation)**
Trend**
1-20/100 000
This pathogen
causes a small
to moderate
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a small
to moderate
proportion of
health care
utilisation due to an
infectious illness
This pathogen
causes a small to
moderate amount
of chronicity or
persistent sequelae
(estimated
prevalence of those
being 0.1-1.0/100
000 population)
0.01-1%
A moderate to
large proportion of
the estimated total
number of events
require public
health actions (25-
75%)
Stable incidence
rates
>20/100 000
This pathogen
causes a large
proportion of
absenteeism due to
an infectious illness
This pathogen
causes a large
proportion of
health care
utilisation due to an
infectious illness
This pathogen
causes a large
amount of
chronicity or
persistent sequelae
(estimated
prevalence of those
being >1.0/100 000
population)
> 1%
Almost all of the
estimated total
number of events
require public
health actions
(>75%)
Increasing
incidence rates
CriteriaScoring Values
-110
TABLE 4
Criteria for scoring to Prioritise diseases/conditions for
surveillance 42Vision 2035: Public Health Surveillance in India: A White Paper
8
9
10
Risk perception of
this pathogen by
general public is low
and it is not high on
political agenda
Preventive potential
seems low or the
disease does not
require prevention or
effective prevention
strategies are well-
established; no
need for significant
strategy modification
Medical treatment is
rarely necessary or
effective regimens
are well-
established; no
need for significant
modifications
Public attention
(including political
agenda and public
perception)*
Prevention
possibilities and
needs (including
vaccines)**
Treatment
possibilities and
needs (including
AMR)**
Risk perception
of this pathogen
by general public
is moderate and
informal political
expectations/
agenda is present
Measures for
prevention are
established but
there is need to
improve their
effectiveness
Medical treatment
regimens are
established but
there is need
to improve their
effectiveness
This pathogen
implies international
duties or its risk
perception by
general public
is high or it is
explicitly high on
political agenda
Need for
prevention is
established but
currently no
effective preventive
measures are
available
Need for medical
treatment is
established,
but currently no
effective treatment
is available or AMR
limits treatment
options
*Assessed against the total burden of infectious diseases
**Assessed for each particular pathogen in question – takes into consideration the availability and adequacy of treatment for each case
of illness.
Source: Yanina Balabanova, Andreas Gilsdorf, Silke Buda, et al, “Communicable Diseases Prioritised for Surveillance and Epidemiological
Research: Results of a Standardized Prioritization Procedure in Germany, PlOS One October 2011 43Vision 2035: Public Health Surveillance in India: A White Paper
IHIP
SI-NACO
Nikshay
RCH portal
Vital Event Registration
Other
CSU/SSU/DSU
CTD
NACO
NHM/Min. of Health
Directorate of Health
Dept. of Health
Registrar of births/deaths
NVBDCP
ICMR
CBHI
26 Regional ICMR
Institutes
8 NCDC Branches
State Reference Labs
District level labs.
Referral linkages for
specimen collection,
transportation & reporting
systems.
Centre
State
District
Technology
Platform
GovernanceTechnical Support
& Research
SI: Strategic Information, NACO: National AIDS Control Organisation, RCH: Reproductive and Child Health, CSU: Central
Surveillance Unit, SSU: State Surveillance Unit, DSU: District Surveillance Unit, CBHI: Central Bureau of Health Intelligence
FIGURE 5 Existing Structure for Public Health Surveillance 44Vision 2035: Public Health Surveillance in India: A White Paper
Source: Revati K Phalkey, Shelby Yamamoto, Pradip Awate, Michael Marx, “Challenges with the implementation of an Integrated
Disease Surveillance and response System: systematic review of the lessons learned, Health Policy and Planning 2015
Health
Systems
Support
System
Utility
Work
Force
Support
Technical/
Technological
Support
• Simplified system
structure
• Coordination with
other sectors and
health programs
• Resources (Financial,
human, logistics and
equipment)
• Leadership (National
& District levels)
• Legal Frameworks
IMPROVED SYSTEM
ATTRIBUTES
IMPROVED CORE
FUNCTIONS
IMPROVED SUPPORT
FUNCTIONS
• Pre and in-service
training for
surveillance and lab
staff
• Supervision
• Retain trained staff
Improved Core
Functions
1. Case Definition
2. Case Confirmation
3. Case Registration
4. Case Notification
5. Data Management
6. Data Analysis
7. Outbreak
Preparedness
8. Outbreak Detection
and Response
9. Feedback
Improved System
Attributes
1. Simplicity
2. Flexibility
3. Timeliness
4. Completeness
5. Consistency
6. Representativeness
7. Acceptability
8. Data Accuracy
9. Sensitivity
10. Positive Predictive Value
11. Stability
• Equipment
(Laboratory, IT,
Transport and
Communication)
• Job Aids (Deadlines,
guidelines,
definitions, reporting
formats etc.)
• Standard Operation
Procedures (Labs
and Outbreaks)
Improved
System
Performance
FIGURE 6
Improved Health Systems Support, Core Functions & System
Attributes 45Vision 2035: Public Health Surveillance in India: A White Paper
Health Unique Identity Number
Standards
Data collection: Mobile app/India
Health Portal/Call centre
Interoperability HIE, NHS
Access and Control by Citizen
Stakeholders
Interdependent
Federated Architecture
between States and
Centre
Technical, Managerial
and Policy Leadership
A skilled workforce
A common lexicon
Global surveillance needs
Data management, storage and
analysis
Informatics, including information
technology
Data access and use
New Evidence/Research
New Case Definition/Risk Factors/
Groups
New Collection Techniques
New Analytical Tools
New Dissemination Techniques
New Stakeholders
India’s Digital Health
Governance
US PHS for the 21st
century
New Data Collection & Sharing Mechanisms
Enhanced Use of New Data Analytics
PHS England
FIGURE 7a
FIGURE 7b
Examples of Key Building Blocks for Surveillance
Key Building Blocks for Vision 2035: PHS in India
Data
Science
Artificial
Intelligence
Machine
Learning
Advanced Health Informatics &
Methods of Data Dissemination
Unique Health
Identity (UHID)
Electronic Health
Records
Amalgamation of
existing disease
surveillance
Complemented by
periodic surveys 46Vision 2035: Public Health Surveillance in India: A White Paper
• New collection techniques could include hand-held devices, mobile platforms and digital
technologies.
• New screening and diagnostic tools could include ‘Point-of-Care’ tests, self-collected and
tested swabs, saliva and urine tests that can be done at home or in community settings,
captured in near real-time and accessed when needed.
• New definitions would primarily include a standardization of definition between clinician,
researcher and epidemiologist, or between veterinary, plant and human sciences.
• New risk factors will emerge as new evidence emerges from research. High levels of
cholesterol were considered until recently to be risk factors for cardiovascular disease, but
this relationship is under question currently.
• New analytical tools can include mathematical modelling, prediction techniques, artificial
intelligence and big data analysis.
• New dissemination techniques include social media and other electronic or digital
platforms.
• New stakeholders have already been previously listed and include the patient/parent,
the practitioner, the private or public institution which may be academic, service-oriented,
research, product development-oriented or policy-centred, the policy maker, the press and
the politician.
• New evidence/research needs no further explanation.
Source: Adapted from Dept. of Health, PHE Transition Team, “Towards a Public Health Surveillance Strategy for England” 2012 India
can consider a seventh new step and include ‘new screening and diagnostic tools’ after new data collection.
FIGURE 8 The Public Health Surveillance Loop
New Collection
Techniques
New Dissemination
Techniques
New Analytical
Tools
New
Stakeholders
Health Care System
Surveillance
Quality Improvements
New case definition
or new risk factors/
groups
New Evidence/
Research Findings
Analysis,
Interpretation
SURVEILLANCE
REPORTING,
INFORMING
DISSEMINATION, FEEDBACK,
RECOMMENDATIONS AND REVIEW
HEALTH CARE SYSTEM
EventData
ActionInformation 47Vision 2035: Public Health Surveillance in India: A White Paper
Source: Barker I, Brownie J, et al “Foresight. Infectious Diseases: preparing for the future: A Vision of Future Detection, Identification
and Monitoring Systems” Office of Science and Innovation, London,2006
ACTION
PLAN
Evaluation of future DIM Systems -
User Challenges
Detection
Identification
Monitoring
Analysis
of Future
Threats
Analysis
of Societal
Contexts
Reviews
of Future
Science
UC 1:
Data Mining
and Data Fusion
- to detect new
diseases
UC 3:
Hand Held
Diagnostics
Device
UC 2:
Genomics and
Post Genomics
to characterise
new diseases
UC 4:
Fast through-
put screening
at ports and
airports
FIGURE 9 Framework for Future Detection, Identification and
Monitoring Systems 48Vision 2035: Public Health Surveillance in India: A White Paper
Cloud data
exchange
platform
Data
validation
Data
warehouse
- Case investigation
- Feedback laboratory diagnosis
EMR
server
LARS
server
Clinical lab
positive results
HospitalsTaiwan CDC
Laboratory information
management system
Hospital
information
system
Physicians Infection control
health care workers
Electronic
medical record
Data
visualization
Web-based
analytical system
Open data
Source: Jian SW, Chen CM, Lee CY, Liu DP. Real-Time Surveillance of Infectious Diseases: Taiwan’s Experience. Health Secur.
2017;15(2):144–153. DOI:10.1089/hs.2016.0107
FIGURE 10 Real-Time Surveillance of Infectious Diseases in Taiwan 49Vision 2035: Public Health Surveillance in India: A White Paper
India launched the Integrated Disease Surveillance Project/Program (IDSP) as a decentralized, state
based surveillance program in 2012. The intent of the program is:
• to detect early warning signals of impending outbreaks
• to help initiate an effective response in a timely manner
• to provide essential data to monitor progress of on-going disease control programs
• to help allocate health resources more efficiently
There is a list of more than 33 acute conditions covered under the IDSP. This list is provided in Table
2. There are three levels of surveillance under this program.
These three levels of surveillance align with the three-tier health system within the country, that
includes sub-centres (SC) and primary health centre (PHC) facilities for provision of primary health
care, community health centres (CHC) and sub-divisional hospitals/block CHC and district hospitals as
secondary levels of care and medical colleges and apex institutes as tertiary care centres.
In addition, many states have also instituted ‘Media Scanning and Verification Cells’ as a function of
the SSU, and very often, these serve as the ‘Early Warning System’ for a political and programmatic
response to a disease outbreak.
The IDSP has categorized the public health response in order to address concerns raised through
surveillance by three levels:
Diagnosis is made on
the basis of symptoms/
clinical pattern observed
by paramedical personnel
and members of the
community. Seven main
conditions are reported
under this including:
fever, persistent cough,
jaundice, diarrhoea,
Acute Flaccid Paralysis/
vaccine preventable
diseases, unusual events
leading to death/
hospitalisation
Diagnosis is made based
on history and clinical
examination by Medical
Officers. 22 diseases and
conditions are listed under
the reporting using the
P form.
Diagnosis is based on
clinical diagnosis confirmed
by an appropriate test.
12 diseases are reported
under the L form.
Syndromic (S form) Presumptive (P form)
Laboratory/Confirmed
(L form)
3 Background, Scope and Organisation of Disease Surveillance in India
Rapid response teams will
work for 8 hours a day for
seven days a week. This is
usually a local response.
Multiple departments
will be involved and the
response will be for a
minimum of seven days,
with teams working for up
to 14 hours each day. This
includes both local, district
and state level response.
This is a 24/7 effort which
will be agency wide. This
geographically extends to
state, regional or national
level response.
Level 1 response Level 2 response Level 3 response Vision 2035: Public Health Surveillance in India: A White Paper The IDSP has successfully integrated data from the Vector Borne Disease Control Program
including data on malaria, filariasis, dengue fever, Japanese Encephalitis, chikungunya and
Kyasanur Forest Disease, among others. Other programs such as the Diarrhoeal Disease Control
Program, zoonotic infections (rabies/dog bite and snake bite), Vaccine Preventable Diseases and
Acute Respiratory Infections are also included. However, vertical programs including the National
AIDS Control Program (NACP), the recently renamed National TB Elimination Program (NTEP)
and the Reproductive and Child Health (RCH) program are not yet fully integrated into the IDSP
as the IDSP took a conscious decision to focus on ‘early warning signals’ for acute conditions,
leaving the large vertical national programs to manage their own systems of surveillance.
Surveillance activities in India are largely either event-based or indicator-based. Event-based
Surveillance is usually restricted to events of public health importance, whereas indicator-based
surveillance includes monitoring of trends, occurrence of new events or compilation and analyses
of a number of events.
A number of activities, though not directly related, also contribute to Disease Surveillance. Few
examples of these are given below.
Notification
Certain diseases are notifiable under the law. While International Health Regulations mandate the
notification of certain diseases (eg., Yellow fever), India has made notification of certain endemic
and nationally prioritised diseases mandatory, such as Tuberculosis (TB). TB is currently notified
on the Nikshay platform. Data on this platform serves as an excellent source of not only tracking
progress in detection of missing cases of TB, but is also used to track outcomes among those
treated in the public and private sector, by type of TB, by co-morbidity (HIV and diabetes) and
other factors.
Sentinel Surveillance
An example is HIV Sentinel Surveillance among antenatal women and those presenting in STI
clinics using sequential sampling during fixed periods of time from select public health facilities.
This data is used as the basis for classification of districts (Type A-D, where A has the highest
prevalence) and for defining the program response. HSS also tracks HIV trends using information
from fixed sites.
Active & Passive Surveillance
Surveillance of Malaria is both active and passive. In active surveillance, health workers visit
house-to-house enquiring about fever, collecting blood smears and administering presumptive
treatment in malaria endemic areas. Passive surveillance is conducted among those presenting to
a health facility with complaints of fever. Any fever, detected by active and passive surveillance,
in a malaria endemic area (defined as an Annual Parasite Index of >2) is presumptively treated
for malaria after a blood smear is collected for examination of malaria parasites. The program
component is restricted to passive surveillance in areas where API is < 2.
Vector Surveillance
Vector surveillance includes indicators such as vector biting rate, vector density, surveillance of
breeding sites, etc., It is used to detect outbreaks of dengue, chikungunya, malaria. Different
local and state governments have launched campaigns to examine and eliminate breeding
sites for mosquitoes, as a preventive measure for Dengue or Malaria outbreaks. While these
campaigns are themselves not considered to be surveillance activities, they are good examples
of preventive actions instituted as a result of information from surveillance that have previously
indicated seasonal trends in disease outbreaks.
Laboratory Surveillance
Apex labs, intermediate and state level laboratories have been set up for most national programs
including TB, HIV and other viral diseases to detect AMR. Pilot initiatives have successfully
50 51Vision 2035: Public Health Surveillance in India: A White Paper
demonstrated that it is feasible to diagnose a substantial proportion of Acute Febrile Illness
or Acute Encephalitis Syndromes through minimal strengthening of collection systems, referral
networks and laboratories at block or district level. AMR is a growing area of public health concern.
Sample surveys
Sample surveys have been conducted to determine risk factors for non-communicable diseases.
Sample surveys are also used to determine the prevalence of disease. An example is the recently
concluded TB prevalence survey conducted by ICMR institutes. The surveys help to estimate or
revalidate the disease burden and programmatic response.
Registries
The main source of information that is being used for estimating the burden of cancer and its
distribution are Cancer registries. These registries have been instituted in Cancer Care Centres,
including Government and a few private sector institutions. Recently, 25 Cancer Care Centres
were recognised and there has been a rapid expansion in the number of regional institutes of
cancer in the country.
Outbreak investigations
Diarrhoea, Acute Encephalitis Syndrome, Acute febrile illness are examples of syndromes wherein
outbreak investigations are conducted. Most acute conditions are reported by front-line health
workers or primary care facilities and include the reporting of diarrhoea/cholera, acute encephalitis
syndrome and acute febrile illness. Media and health authorities also routinely report outbreaks
of food poisoning or sudden increase in hospitalisation due to a certain syndrome. This serves as
an early warning signal for most outbreak investigations that are then investigated and confirmed
by a rapid response team set up at district/state level. A single case of acute flaccid paralysis was
considered to be an epidemic, under the National Polio Eradication program.
Special Studies
The Integrated Behavioural and Biological Surveys (IBBS) among at-risk populations for HIV
infection is an example of special studies contributing to surveillance of disease trends and trends
in risk behaviour.
The Organisation of Disease Surveillance in India:
Surveillance activities in India are organised at three levels: National, State and District.
CSU is integrated administratively and financially with the National Centre for Disease
Control (NCDC), New Delhi and established by the Ministry of Health and Family Welfare
for the Global Health Security Agenda (GHSA). The CSU has 14 technical centres/
divisions, including epidemiology, microbiology, zoonosis, medical entomology and vector
management, IDSP, Centre for AIDS and Related Diseases, biochemical and toxicology,
biotechnology, parasitic diseases, malariology and coordination, occupational and
environmental health, non-communicable diseases, statistics and M&E, planning, budget
and administration. The CSU runs a two-year MPH course in Field Epidemiology.
There is SSU in each State/UT with a regular officer identified as State Surveillance Officer
(SSO). The SSO is supported by 7 contractual staff who include Training manager, Finance
manager, Data manager, Epidemiologist, Microbiologist, Entomologist and a recently
included Veterinary consultant.
There is one DSU in each district with a regular officer as District Surveillance Officer (DSO),
who is supported by 3 contractual staff.
CENTRAL SURVEILLANCE UNIT (CSU)
STATE SURVEILLANCE UNIT (SSU)
DISTRICT SURVEILLANCE UNIT (DSU) 52Vision 2035: Public Health Surveillance in India: A White Paper
Data flows into the District Surveillance Units from peripheral health institutions as depicted in
Figure 11.
At the national level, the CSU coordinates with the WHO, the Indian Council of Medical Research
(ICMR), the National Institute of Communicable Diseases (NICD) and the Central Bureau of Health
Information (CBHI) as shown in Figure 12. Data pertaining to Surveillance from the national
programs including National TB Elimination Program (NTEP), National AIDS Control Organization
(NACO), Reproductive and Child Health (RCH) and National Vector Borne Disease Control
Program (NVBDCP) is to be hosted, analyzed and available for concerned stakeholders.
DSU
SSU
CSU
PHCsPvt. Practitioners
Nursing Homes
Private Hospitals
Corporate Hospitals
Other Hospitals:
ESI, Municipal
Rly., Army etc.
Programme
Officers
Sub-Centres
Private Labs
CHCs
DHs
MCs
Public Labs
Figure 11: Information Flow - Weekly Surveillance System 53Vision 2035: Public Health Surveillance in India: A White Paper
EMR
NICD
ICMRCBHI
RCHRNTCPNVBDCPNACO
CSU
National
Programs
WHO
Outbreak Investigation
& Rapid Response
Programme Monitoring
NCD SurveillanceMIS & Report
The Indian Council of Medical Research (ICMR) - Role in Surveillance:
The ICMR’s contribution in understanding various diseases of national importance such as
malaria, Japanese Encephalitis, tuberculosis, AIDS, Kala-azar, Filariasis, Leprosy and Poliomyelitis
is remarkable. Additionally, ICMR has made extensive contributions in the areas of nutrition,
reproduction and maternal and child health, occupational and environmental health with research
complementing health systems. The ICMR has a regional network of 26 institutes. They are involved
in the evaluation of new drugs, insecticides, vaccines, devices, diagnostic kits. Additionally, they
play a key role in interventions for all diseases of national health priority along with neglected
and regional diseases. ICMR has linked 106 viral research laboratories, which are used for lab
testing in epidemic outbreaks and is involved in mathematical modelling for Malaria and Dengue
in North East. Point-of-Care devices are being piloted for Leptospirosis. ICMR is also supporting
a ‘Center for One Health’ for surveillance of nosocomial infections and hospital infection control
in Nagpur, and a National Centre for Occupation Health conducts surveillance of heavy metals in
plants. This Centre has a Surveillance program for Injuries and Accidents. ICMR is working towards
developing systems for interoperability, which is expected to be finalized in about a year’s time.
During the recent outbreak, the National Institute of Virology confirmed the presence of Nipah
Virus in Kerala, India. ICMR has funded pilots and projects to demonstrate that Kala-azar (Visceral
Leishmaniasis) can be eliminated. ICMR also set up a Sentinel Surveillance for Congenital Rubella
Syndrome (CRS) in India with six sites and a hospital-based sentinel surveillance for Pneumonia
and Invasive Bacterial Diseases (IBD). The ICMR-National Institute of Cholera and Enteric Diseases
(ICMR- NICED) houses the National AMR Hub and Repository and is envisaged to carry forward
the AMR research in India from a multidimensional approach. There is potential to integrate IDSP
surveillance of bacterial infectious diseases with AMR research and translate this into a National
Programme of AMR in future.
From Old to New - From Integrated Disease Surveillance Program to Integrated Health
Information Platform:
In the traditional system of surveillance which is still operational in the majority of the states in
India, the IDSP captures aggregate data, is paper-based, is not able to link data from S, P and L
forms, delivers only weekly surveillance and monitors only 13 health conditions (Figure 13).
Figure 12: Linkages of CSU at Central Level 54Vision 2035: Public Health Surveillance in India: A White Paper
Source: Karnataka Best Practice ppt @ Gujarat Summit 2019
VILLAGE
(655075)(Auxiliary Nurse
Midwife, or Male
Health Worker)
Weekly household
visits to collect data
B-PHC or CHC data
collected from PHCs
(Medical Doctor +
helper)
(District Surveillance Officer,
Data Manager, Data Entry
Operator)
(State Surveillance Officer,
Data Manager, Data Entry
Operator)
Laboratory Presence
Laboratory Presence
Laboratory Presence
SUB-DISTRICT
(6267)
DISTRICT
(707)
STATE
(36 STATES/UTs)
Sub Center
Primary Health Center
One Consolidate “S”
form per Sub-center
per week
Paper forms
Paper forms
Spreadsheets
One Consolidate ”P”
form/PHC/week +
”L” forms
Paper forms are
coverted in to
electronic data
Electronic data, kept
in the form of XL sheets
or on a DB/Portal
Email-
Web
Entry
hand
delivered
hand
delivered
Block PHC or
Community Health Center
District Surveillance Unit
State Surveillance Unit
The new IDSP now uses the IHIP (Figure 14) to capture individualized data that can be
disaggregated by age, gender and locality, links data from Syndrome, Presumptive and Laboratory,
Early Warning Signals 1 and 2 forms, captures near real-time or daily surveillance data, provides
analysis on mobile and electronic devices and monitors more than 33+ health conditions. The IHIP
is already integrated with the NVBDCP, but full integration has not yet been achieved for the other
national programs.
The IHIP is an open platform and has the ability to connect with eHospital Systems and the new
National Health Management Information System. It can thus connect with both public and private
hospitals, laboratories, and research centers under one platform to facilitate the exchange of
health data in a secure manner. Data from the IHIP can be used to describe and analyze geographic
variations in diseases in the context of demographic, environmental, behavioural , socioeconomic,
genetic, and infectious risk factors. Data from the IHIP can also be used to explore geographic
locations of persons with their socioeconomic and demographics attributes as data captures geo-
coordinates and socio-demographic characteristics. However, the IHIP needs further refinement
to:
1. Integrate Communicable disease with NCDs as comorbidity using unique patient identifier.
2. Capture complications and proportions with severe disease as this is useful to decide on
appropriate action. For eg., Proportion with severe dengue fever, staging for cancer.
3. Integrate prevention (vaccine/chemoprophylaxis) and treatment data.
4. Integrate other types of data such as immunization coverage, AMR, nutrition status, vector
indices, climatic factors, health system availability.
5. Capture the entire continuum in care including outcomes such as death, cure/recovery/
completed treatment, relapse/recurrence, number of episodes, etc. for enhanced understanding
of disease spectrum/prognosis and health resource planning.
Figure 13: Conventional IDSP’s Data Collection Process 55Vision 2035: Public Health Surveillance in India: A White Paper
HIV Surveillance:
HIV Sentinel Surveillance (HSS) was perhaps one of the first nation-wide surveillance systems
that initially helped to confirm the presence of HIV in India through sentinel sites and designated
laboratories beginning in 1992. By 1997, HSS expanded to both antenatal and high-risk
populations which provided critical insights on the geographic distribution of the HIV epidemic
within India. The HSS thus helped to identify six states with high prevalence. In 2003, HSS
expanded to cover every district in all high prevalence states and to have a state representative
sample for regions that were not yet declared to be high HIV prevalent. In 2006, the National
Family Health Survey (NFHS) 3 for the first time integrated HIV prevalence among the indicators
that were measured. About a decade later, the National AIDS Control Organisation (NACO)
instituted Integrated Behavioural and Biological Surveillance (IBBS) which enabled tracking of not
only the disease prevalence and distribution, but also helped to understand the risk factors that
were determinants and drivers of the epidemic across geographies and sub-population groups.
HIV surveillance thus provides useful information to estimate the burden of HIV, the distribution
by population and place, and trends over time. Additionally, program data has been useful in
estimating the new infections and their distribution, and in estimating over time, the reduction in
death rates among those on treatment.
Polio surveillance in India:
India’s Acute Flaccid Paralysis (AFP) surveillance system for detecting poliovirus transmission was
considered to be one of the most sensitive surveillance systems in the world. The surveillance
network was widespread. It included both public and private sector reporting sites. It even
included non-allopathic healthcare providers and traditional healers. These sites would give a
call on mobile phone to a designated district surveillance/ immunization officer whenever a case
of AFP was detected. The district immunization officer would then ensure sample collection
for laboratory diagnosis. India both met and surpassed all of the WHO AFP Surveillance
Source: Karnataka Best Practice ppt @ Gujarat Summit 2019
VILLAGE
(655075)
Mobile reporting
Portal access
Mobile reporting
Portal access
Mobile Reporting
Portal access
Mobile Reporting
Proposed System: Portal access allows reporting of all data from DSU, CSU, SSU to CSU/IDSP in near real-time.
Mobile reporting is both store and forward and near real-time. Data analytics and results will be accessible at all
levels for action.
Sub Center or
Health Sub Center
Primary Health Center
Block PHC or
Community Health Center
Broadband Connectivity
Data Entry
Computer
Data
Entry
Comp.
Data
Entry
Comp.
Data
Entry
Comp.
Data
Center
Broadband Connectivity
Broadband and Satellite-based
Connectivity
District Surveillance
Unit
State Surveillance
Unit
SUB-DISTRICT
(6267)
DISTRICT
(707)
STATE
(36 STATES/UTs)
Laboratory Presence
Laboratory Presence
Laboratory Presence
Figure 14: New IHIP Real-Time Data Flow Processes 56Vision 2035: Public Health Surveillance in India: A White Paper
global performance indicators over 10 years. Following this, India was certified polio free. The
development of surveillance performance indicators is unique to AFP surveillance for Polio and
is an innovation worth applying to other diseases/health conditions of public health importance.
India’s AFP surveillance system provides evidence of operational feasibility for polio surveillance.
It also provides a road map for global quality surveillance in low and middle income countries.
System for Early Warning Based on Emergency Data (SEED):
SEED was a collaborative project of the GVK Emergency Management and Research Institute
(EMRI), India, and GEOMED Research, Germany to systemically explore the use of emergency
data for syndromic surveillance at the primary care level in Andhra Pradesh. The project is a
combination of a database and corresponding algorithm and GIS tools. EMS (emergency
management system) data are generated and captured automatically at the state dispatch centre
in Hyderabad. It serves as an early warning system for disease outbreaks through automatic
comparison of real time data and pre-determined thresholds. The EMS data are generated and
captured in 15 states and 2 union territories.
National Health Policy and Public Health Surveillance:
The National Health Policy 2017 clearly articulated that India needs to accelerate progress in order
to achieve the Millennium Development Goals by 2015 and the Sustainable Development Goals
by 2030. In alignment with the Universal Health Coverage objective and its guiding principles
of ensuring universal health as a right and entitlement, guaranteed access to an essential health
package including primary, secondary and tertiary care and freedom of choice for patients
between the public and private sector, ensuring equity, non-exclusion and non-discrimination,
comprehensive quality care, financial protection, and protection of patient’s rights and respect
for patient’s choice, portability and continuity of care, community participation and putting health
in people’s hand, the plan also set ambitious targets. Prominent among these targets was an
increased allocation of GDP for health from its existing level to 2.5% by the end of the plan
and to 3% by 2022, ensuring availability of free medicines and reducing out-of-pocket services.
The policy stated that 70% of all health care resources would be dedicated towards improving
primary health care. Convergence of all vertical disease control programs under the umbrella of
the National Health Mission, the integration of the delivery of all health services, universal and
cashless access to an essential health package including essential medicines is stressed. A Health
information system that captures both population, community and facility based information,
linking all providers, laboratories, and public health managers, so that it is able to provide
information to monitor disease burden and support decision making and resource allocation was
laid out as a priority. Public health surveillance, research and control of risks and threats to public
health are prominently included in the essential health package. 57Vision 2035: Public Health Surveillance in India: A White Paper
1. Thacker S B, Berkelman R L. Public Health Surveillance in the United States. Epidemiologic
Reviews.1988.DOI:10.1093/oxfordjournals.epirev.a036021
2. WHO.STEPwise approach for NCD surveillance.2003
3. DGHS/MoHFW. IDSP Medical Officer Manual.2005
4. WHO. Communicable Disease Surveillance and Response systems – a guide to monitoring
and evaluating.2006
5. Barker I, Brownie J, et al. Foresight. Infectious Diseases: preparing for the future: A Vision of
Future Detection, Identification and Monitoring Systems. Office of Science and Innovation,
London.2006
6. Lee L M, Thacker. Principles and Practice of Public Health Surveillance.2010
7. Balabanova Y, Gilsdorf A, Buda S, et al. Communicable Diseases Prioritized for Surveillance
and Epidemiological Research: Results of a Standardized Prioritization Procedure in Germany.
PlOS One. October 2011
8. Bernard C K Choi. The Past, Present and Future of Public Health Surveillance. Hindawi
Scientifica. page 26.2012. DOI 10.6064/2012/875253
9. Thacker S B, Qualters J R, Lee L M…Public health surveillance in the United States: evolution
and challenges. MMWR Weekly Report.CDC.2012
10. Washington R G. Integrated Vector Control Measures in Managing Vector Borne Diseases.
Cover Story. Health Action.2012
11. Department of Health, PHE Transition Team. Towards a Public Health Surveillance Strategy
for England.2012
12. Planning Commission, GoI.12th five-year plan-faster, more inclusive and sustainable growth
– volume 1.2013
13. WHO. Global Action Plan for prevention and control of NCD 2013-2020.2013
14. Gururaj G. Growing burden and impact of road crashes in India – need for safe systems
approach. International J of Vehicle Safety. Vol 7.2014.
15. DGHS. Joint Monitoring Mission Report.2015
16. Phalkey R K, Yamamoto S, Awate P, Marx M. Challenges with the implementation of an
Integrated Disease Surveillance and response System: systematic review of the lessons
learned. Health Policy and Planning.2015 Feb;30(1):131-43. DOI: 10.1093/heapol/czt097.
Epub 2013 Dec 20. PMID: 24362642
17. Krafft T, Pilot E, Sarkar B K, Ryland P, Reeves L, Singh V. Research and Innovations guiding
Public Health Surveillance in the Twenty-first century. Book. Transforming Public Health
Surveillance Elsevier. Chapter 30.2016.
18. Pan Canadian Public Health Network. Blueprint for a Federated System for Public Health
Surveillance in Canada: Vision and Action Plan.Ottawa.2016
19. Ministry of Health and Family Welfare. GOI. National Health Policy 2017. https://www.nhp.
gov.in/nhpfiles/national_health_policy_2017.pdf
20. NCDC, DGHS. Training manual for medical officers for prevention, control and population
level screening of hypertension, diabetes and common cancers.2017
21. CDC. Power-point document Enhancing Real-time Sentinel Infectious Disease Surveillance in
India: Background information for Preparation of State PIP.2017.
22. Pilot E, Roa R, Jena B, et al. Towards Sustainable Public Health Surveillance in India: Using
Routinely Collected Electronic Emergency Medical Service Data for Early Warning of Infectious
Diseases. Sustainability. MDPI. 2017.DOI:10.3390/su9040604
23. Jian S W, Chen C M, Lee C Y, Liu D P. Real-Time Surveillance of Infectious Diseases: Taiwan’s
Experience. Health Secur. 017;15(2):144–153.DOI:10.1089/hs.2016.0107
24. NACO.HIV Sentinel Surveillance, Technical Brief – 2017.December 2017
25. Martin D, Miller A P, et al. Canada’s universal health-care system: achieving its potential.
Lancet series.2018.DOI:10.1016/S0140-6736(18)30181-8
4 Bibliography 58Vision 2035: Public Health Surveillance in India: A White Paper
26. NHSRC. Ayushman Bharat: Comprehensive Primary Health Care through Health and Wellness
Centres – Operational Guidelines.2018
27. Bhatia R, Katoch V M, Inoue H. Creating political commitment for antimicrobial resistance in
developing countries. Indian J Med Res 149, February. 2019.DOI: 10.4103/ijmr.IJMR_1980_17
28. Taweewigyakarn P. Public Health Surveillance. Thailand: power-point document accessed
from http://www.interfetpthailand.net/
29. NCDC, IHIP manuals. User Manual, S form, P form, L form, Event outbreak manual, Media
scanning and verification cell manual, Revised Guidelines for the collection, storage and
transportation of samples for the diagnosis of Influenza, Office Note: Revised TA/DA guidelines
for training, Weekly report 34, 39, Monthly report April 2019.June 2019
30. NITI Aayog. National Digital Health Blueprint. July 2019
31. NITI Aayog. India Health Sector Risk Pooling – Challenges, Opportunities and Options for
Improvement. 2019
32. NITI Aayog. Healthy States: Progressive India: Health Index. June 2019
33. https://www.cdc.gov/mmwr/index.html
34. https://www.promedmail.org/index.php
35. https://www.canada.ca/en/public-health/services/surveillance.html
36. NITI Aayog. Internal notes on visit of Mr Alok Kumar to Public Health Agency Canada.2019.
37. Krishnamurthy J, et al. Designing a comprehensive NCD program for hypertension and
diabetes at the primary care level: evidence and experience from urban Karnataka, S India.
BMC Public Health.2019
38. WHO, FAO, others. Enhancing progress towards Rabies Elimination by 2030 in SAARC
countries – workshop report. June 2019
39. USAID. Community event based surveillance of priority human and zoonotic diseases in
Senegal. Measuer Evaluation. September 2019
40. Sinclair A J. Sub-sahara Africa – The impact and challenge of type 2 diabetes mellitus requiring
urgent and sustainable public health measures. Eclinical Medicine. ScienceDirect, October
2019. DOI: 10.1016/j.eclinm.2019.10.005
41. WHO. Short Note on IDSP.November2019
42. WHO.IHIP presentation from Karnataka at National Summit, Gujarat. November 2019
43. IDSP.nic.in: last accessed on November 25, 2019
44. Eclinical Medicine. Editorial on Leprosy – forgotten not gone. ScienceDirect. October 2019
45. Wagstaff A, Neelsen S.A comprehensive assessment of UHC in 111 countries: a retrospective
observational study. Lancet GlobHealth. December.2019. DOI: 10.1111/j.1365-4632.2011.
04961.x
46. Fullman N., Lozano R. Measurement matters: who and what counts on the road to UHC.
Lancet GlobHealth.December.2019.DOI:10.1016/S2214-109X(19)30499-1
47. Sudarshan M K, Narayana D H A. Appraisal of Surveillance in Human Rabies and Animal Bites
in Seven States of India. IJPH, December 2019. DOI: 10.4103/ijph.IJPH_377_19
48. Centrient Pharmaceuticals. Letter of request to include AMR in the Vision 2035 document on
Surveillance. January 2020
49. Sarin S.Note on IDSP and Essential Diagnostics List. January 2020
50. WHO. Overview of Ending Cholera – A Global Roadmap to 2030.January 2020.
51. Bhatia R. Need for integrated surveillance at human-animal interface for rapid detection and
response to emerging coronavirus infections using One Health approach. Perspective. Indian
J or Med Res 151.February 2020. DOI: 10.4103/ijmr.IJMR_623_20
52. Bhatia R, Abraham P. Time to revisit national response to pandemics. Indian J of Medical Res
151, pp111-113.February-March 2020. DOI: 10.4103/ijmr.IJMR_846_20 59 Health vertical
National Institute for Transforming India
NITI Bhawan, Sansad Marg
New Delhi – 110001
healthdiv-pc@gov.in
011 - 23042547
ISBN 978-81-949510-6-3
DOI: 10.6084/m9.figshare.14093323